Family Medicine Aquifer Cases Test Questions
And Answers Verified 100% Correct
A 58-year-old male experiencing homelessness presents to the emergency department
with a decreased level of consciousness. Urine microscopy is performed, and numerous
calcium oxalate crystals are present. What is the most likely explanation for the calcium
oxalate crystals seen in his urine?
A. Ethylene glycol ingestion
B. Excessive ethanol intake
C. Kidney stones
D. Methanol poisoning
E. Tricyclic antidepressant overdose - ANSWER- The ANSWER is A. From IM 26.
A 23-year-old male is brought to the hospital on a hot summer evening with an altered
mental status. He has no chronic medical conditions and takes no prescribed
medications. He is known to drink alcohol regularly and use street drugs. He reportedly
attended a party hours before being found confused and combative in his apartment,
which is without air conditioning. Laboratory examination reveals a serum sodium of 160
and a creatinine of 2.1 mg/dL. What is the most likely cause of his hypernatremia?
A. Alcohol intoxication with vomiting
B. Diuresis from excessive beer intake
C. Excess salty food intake
D. Heroin overdose
E. MDMA ("ecstasy") intoxication - ANSWER- The ANSWER is A. From IM 26.
A 32-year-old male with type 1 diabetes mellitus presents to the emergency department.
He has had recent suicidal ideation and recent admissions for diabetic ketoacidosis. He
has a suspected, but not proven, ethylene glycol overdose, as his friend found an empty
bottle of antifreeze in his house. His arterial pH is 7.25, his serum bicarbonate level is
14 mEq/L, and his osmolar gap is 12 mOsm/kg H2O. The ethylene glycol level is
pending. What should be the immediate next step?
A. Consult nephrology to initiate hemodialysis
B. Order fomepizole
C. Send urine to evaluate for calcium oxalate crystals
D. Start an intravenous bicarbonate continuous infusion
E. Start an intravenous insulin drip - ANSWER- The ANSWER is B. From IM 26.
A 58-year-old female with a history of hypertension and hyperlipidemia on
chlorthalidone and simvastatin presents to her physician with concerns of fatigue and
constipation. Physical exam is significant for dry mucous membranes, her pulse is 105
,beats/minute, and there is hard stool in the rectal vault. Her blood pressure is normal.
Labs are significant for: glucose 100 mg/dL, sodium 140mEq/L, potassium 4.0mEq/L,
calcium 12.0 mg/dL, thyroid-stimulating hormone (TSH) 3.5 mU/L, and parathyroid
hormone (PTH) 18 pg/mL. What is the most likely cause of this patient's hypercalcemia?
A. Adrenal insufficiency
B. Chlorthalidone
C. Hyperparathyroidism
D. Hyperthyroidism
E. Metastasis to the bone - ANSWER- The ANSWER is B. From IM 27.
An 85-year-old female with widely metastatic breast cancer presents to the emergency
department with confusion, fatigue, constipation, and global weakness. Her daughter
reports that she has been drinking over three liters a day of water and juice. She has
not had a bowel movement in five days. Her labs are significant for a calcium of
15mg/dL. An electrocardiogram (ECG) is ordered. What finding is the hypercalcemia
most likely to cause on her ECG?
A. Atrial fibrillation
B. PR segment depression
C. Shortened QT interval
D. Sinus tachycardia
E. T-wave inversion - ANSWER- The ANSWER is C. From IM 27.
A 65-year-old female presents to the emergency department with one week of
progressive confusion, fatigue, and global weakness. Her history is significant for widely
metastatic renal-cell carcinoma. She has not had a bowel movement in five days.
Laboratory studies are shown.
Sodium: 142 mEq/L
Potassium: 4.2 mEq/L
Chloride: 105 mEq/L
Bicarbonate: 18 mEq/L
Calcium: 15 mg/dL
Albumin: 3.9 g/dL
Goals of care are discussed with her wife, and she requests inpatient therapy. Along
with saline resuscitation, which medication should be given to help lower her calcium
levels?
A. Acetazolamide
B. Calcitonin
C. Furosemide
D. Hydrocholorthiazide
E. Spironolactone - ANSWER- The ANSWER is B. From IM 27.
A 55-year-old male with a 40-pack-per-year smoking history presents with a several
month history of a 15-pound unintentional weight loss, and a worsening cough. He
,reports polyuria and polydipsia. Physical exam is significant for a wheezing in the lower
lung fields bilaterally. His calcium level is 12.5 mg/dL. A chest x-ray is significant for a 2
cm lung nodule next to the left bronchus and prominent hilar lymphadenopathy. What is
the next-best test that should be ordered to work up this patient's hypercalcemia?
A. 1,25(OH)2 Vitamin D
B. Cortisol
C. Parathyroid hormone (PTH)
D. Parathyroid hormone-related peptide (PTH-rp)
E. Thyroid stimulating hormone (TSH) - ANSWER- The ANSWER is C. From IM 27.
A 35-year-old female comes to the clinic because of a three-month history of abdominal
distension. She has concerns about diffuse abdominal pain, polyuria, and polydipsia.
She has lost 15 pounds over the past six months despite not changing her diet. She
was previously healthy. Physical exam is significant for a distended abdomen with
shifting dullness and a fluid wave. Laboratory studies are shown: Serum calcium: 12.5
mg/dL Parathyroid hormone: 8 pg/mL 1,25(OH)2 Vitamin D: 40 pg/mL
5x3 cm mass in the left adnexal area. Which of the following is the most-likely cause of
this patient's findings?
A. Direct production of parathyroid hormone (PTH) by the malignant cells
B. Direct synthesis of 1,25(OH)2 Vitamin D by the tumor
C. Osteoclast activation and release of calcium from an osteolytic tumor
D. Parathyroid hormone-related protein activation of osteoclasts
E. Parathyroid hormone-related protein increasing renal calcium elimination -
ANSWER- The ANSWER is D. From IM 27.
A 58-year-old female presents to the clinic with concern for chest pain over the past
three months. She describes the pain as sharp and stabbing, in the mid-sternal region,
lasting for one to two minutes, occurring a few times a day. The pain can come on at
rest or with exertion and resolves on its own. It has not become worse since it began.
There is no associated diaphoresis, shortness of breath, nausea, jaw pain, or pain with
movement, eating, or laying supine. She has a 10-year history of obesity and
hypertension for which she takes chlorthalidone and lisinopril. She was recently
diagnosed with diabetes that has been controlled by diet. Physical examination shows
her pulse is 86 beats/minute, respiration rate is 16 breaths/minute, and blood pressure
is 135/85 mmHg. Her lungs are clear, heart sounds are normal, and there is no chest
wall tenderness to palpation or abdominal tenderness. There is no peripheral edema.
How would you best characterize her chest pain?
A. Atypical angina
B. Gastroesophageal reflux
C. Musculoskeletal
D. Stable angina
E. Unstable angina - ANSWER- The ANSWER is A. From IM 02.
, A 42-year-old female presents to the emergency department with concern for mild chest
pain lasting three to four minutes with vigorous exercise, three times over the past
week. She has no past medical history and is not taking any medications or
supplements. She has no family history of cardiac or pulmonary disorders. She follows
a vegetarian diet, exercises regularly, and is training for a half-marathon. Physical
examination shows her pulse is 66 beats/minute, respiration rate is 16 breaths/minute,
and blood pressure is 110/70 mmHg. Her lungs are clear, heart sounds are normal, and
there is no lower-extremity edema. Which of the following is the most likely laboratory
study in the acute setting to assist with the diagnosis?
A. Brain natriuretic peptide (BNP)
B. Complete blood count (CBC)
C. Hemoglobin A1c
D. Low-density lipoprotein (LDL)
E. Triglycerides - ANSWER- The ANSWER is B. From IM 02.
Although cardiac causes of chest pain should be considered, it is important to consider
other sources of pain. Anemia may cause chest pain by decreasing oxygen carrying
capacity.
A 66-year-old male presents to his primary care provider with concern for intermittent
chest pain. He describes several episodes a week of pressure under his sternum that
comes on with exertion, lasts for about 5 to 10 minutes and is improved with rest, over
the last two weeks. He notes some shortness of breath with the pain, but denies any
associated diaphoresis, nausea, or jaw pain. He has a history of hypertension and
hyperlipidemia treated with lisinopril, simvastatin, and aspirin. He exercises at a gym for
30 minutes, two to three times per week. Physical examination shows his pulse is 78
beats/minute, respiratory rate is 16 breaths/minute, and blood pressure is 145/80
mmHg. His lungs are clear, heart sounds are normal, and there is no lower-extremity
edema. His electrocardiogram (ECG) is normal. Which of the following is the
mostappropriate next step in his workup? A. Cardiac catheterization
B. Computed tomography (CT) scan
C. Echocardiogram
D. Pharmacologic stress test with imaging
E. Treadmill stress test without imaging - ANSWER- The ANSWER is A. From IM 02.
The patient should proceed directly for a cardiac catheterization. His symptoms meet
the criteria for angina (substernal chest discomfort with a characteristic duration and
features, exertional in nature and relieved with rest or nitroglycerin) and since it is
relatively new and started within the month, it should be considered unstable angina. In
addition, he has considerable risk factors, thus his pretest probability is high for cardiac
disease and cardiac catheterization is recommended.
And Answers Verified 100% Correct
A 58-year-old male experiencing homelessness presents to the emergency department
with a decreased level of consciousness. Urine microscopy is performed, and numerous
calcium oxalate crystals are present. What is the most likely explanation for the calcium
oxalate crystals seen in his urine?
A. Ethylene glycol ingestion
B. Excessive ethanol intake
C. Kidney stones
D. Methanol poisoning
E. Tricyclic antidepressant overdose - ANSWER- The ANSWER is A. From IM 26.
A 23-year-old male is brought to the hospital on a hot summer evening with an altered
mental status. He has no chronic medical conditions and takes no prescribed
medications. He is known to drink alcohol regularly and use street drugs. He reportedly
attended a party hours before being found confused and combative in his apartment,
which is without air conditioning. Laboratory examination reveals a serum sodium of 160
and a creatinine of 2.1 mg/dL. What is the most likely cause of his hypernatremia?
A. Alcohol intoxication with vomiting
B. Diuresis from excessive beer intake
C. Excess salty food intake
D. Heroin overdose
E. MDMA ("ecstasy") intoxication - ANSWER- The ANSWER is A. From IM 26.
A 32-year-old male with type 1 diabetes mellitus presents to the emergency department.
He has had recent suicidal ideation and recent admissions for diabetic ketoacidosis. He
has a suspected, but not proven, ethylene glycol overdose, as his friend found an empty
bottle of antifreeze in his house. His arterial pH is 7.25, his serum bicarbonate level is
14 mEq/L, and his osmolar gap is 12 mOsm/kg H2O. The ethylene glycol level is
pending. What should be the immediate next step?
A. Consult nephrology to initiate hemodialysis
B. Order fomepizole
C. Send urine to evaluate for calcium oxalate crystals
D. Start an intravenous bicarbonate continuous infusion
E. Start an intravenous insulin drip - ANSWER- The ANSWER is B. From IM 26.
A 58-year-old female with a history of hypertension and hyperlipidemia on
chlorthalidone and simvastatin presents to her physician with concerns of fatigue and
constipation. Physical exam is significant for dry mucous membranes, her pulse is 105
,beats/minute, and there is hard stool in the rectal vault. Her blood pressure is normal.
Labs are significant for: glucose 100 mg/dL, sodium 140mEq/L, potassium 4.0mEq/L,
calcium 12.0 mg/dL, thyroid-stimulating hormone (TSH) 3.5 mU/L, and parathyroid
hormone (PTH) 18 pg/mL. What is the most likely cause of this patient's hypercalcemia?
A. Adrenal insufficiency
B. Chlorthalidone
C. Hyperparathyroidism
D. Hyperthyroidism
E. Metastasis to the bone - ANSWER- The ANSWER is B. From IM 27.
An 85-year-old female with widely metastatic breast cancer presents to the emergency
department with confusion, fatigue, constipation, and global weakness. Her daughter
reports that she has been drinking over three liters a day of water and juice. She has
not had a bowel movement in five days. Her labs are significant for a calcium of
15mg/dL. An electrocardiogram (ECG) is ordered. What finding is the hypercalcemia
most likely to cause on her ECG?
A. Atrial fibrillation
B. PR segment depression
C. Shortened QT interval
D. Sinus tachycardia
E. T-wave inversion - ANSWER- The ANSWER is C. From IM 27.
A 65-year-old female presents to the emergency department with one week of
progressive confusion, fatigue, and global weakness. Her history is significant for widely
metastatic renal-cell carcinoma. She has not had a bowel movement in five days.
Laboratory studies are shown.
Sodium: 142 mEq/L
Potassium: 4.2 mEq/L
Chloride: 105 mEq/L
Bicarbonate: 18 mEq/L
Calcium: 15 mg/dL
Albumin: 3.9 g/dL
Goals of care are discussed with her wife, and she requests inpatient therapy. Along
with saline resuscitation, which medication should be given to help lower her calcium
levels?
A. Acetazolamide
B. Calcitonin
C. Furosemide
D. Hydrocholorthiazide
E. Spironolactone - ANSWER- The ANSWER is B. From IM 27.
A 55-year-old male with a 40-pack-per-year smoking history presents with a several
month history of a 15-pound unintentional weight loss, and a worsening cough. He
,reports polyuria and polydipsia. Physical exam is significant for a wheezing in the lower
lung fields bilaterally. His calcium level is 12.5 mg/dL. A chest x-ray is significant for a 2
cm lung nodule next to the left bronchus and prominent hilar lymphadenopathy. What is
the next-best test that should be ordered to work up this patient's hypercalcemia?
A. 1,25(OH)2 Vitamin D
B. Cortisol
C. Parathyroid hormone (PTH)
D. Parathyroid hormone-related peptide (PTH-rp)
E. Thyroid stimulating hormone (TSH) - ANSWER- The ANSWER is C. From IM 27.
A 35-year-old female comes to the clinic because of a three-month history of abdominal
distension. She has concerns about diffuse abdominal pain, polyuria, and polydipsia.
She has lost 15 pounds over the past six months despite not changing her diet. She
was previously healthy. Physical exam is significant for a distended abdomen with
shifting dullness and a fluid wave. Laboratory studies are shown: Serum calcium: 12.5
mg/dL Parathyroid hormone: 8 pg/mL 1,25(OH)2 Vitamin D: 40 pg/mL
5x3 cm mass in the left adnexal area. Which of the following is the most-likely cause of
this patient's findings?
A. Direct production of parathyroid hormone (PTH) by the malignant cells
B. Direct synthesis of 1,25(OH)2 Vitamin D by the tumor
C. Osteoclast activation and release of calcium from an osteolytic tumor
D. Parathyroid hormone-related protein activation of osteoclasts
E. Parathyroid hormone-related protein increasing renal calcium elimination -
ANSWER- The ANSWER is D. From IM 27.
A 58-year-old female presents to the clinic with concern for chest pain over the past
three months. She describes the pain as sharp and stabbing, in the mid-sternal region,
lasting for one to two minutes, occurring a few times a day. The pain can come on at
rest or with exertion and resolves on its own. It has not become worse since it began.
There is no associated diaphoresis, shortness of breath, nausea, jaw pain, or pain with
movement, eating, or laying supine. She has a 10-year history of obesity and
hypertension for which she takes chlorthalidone and lisinopril. She was recently
diagnosed with diabetes that has been controlled by diet. Physical examination shows
her pulse is 86 beats/minute, respiration rate is 16 breaths/minute, and blood pressure
is 135/85 mmHg. Her lungs are clear, heart sounds are normal, and there is no chest
wall tenderness to palpation or abdominal tenderness. There is no peripheral edema.
How would you best characterize her chest pain?
A. Atypical angina
B. Gastroesophageal reflux
C. Musculoskeletal
D. Stable angina
E. Unstable angina - ANSWER- The ANSWER is A. From IM 02.
, A 42-year-old female presents to the emergency department with concern for mild chest
pain lasting three to four minutes with vigorous exercise, three times over the past
week. She has no past medical history and is not taking any medications or
supplements. She has no family history of cardiac or pulmonary disorders. She follows
a vegetarian diet, exercises regularly, and is training for a half-marathon. Physical
examination shows her pulse is 66 beats/minute, respiration rate is 16 breaths/minute,
and blood pressure is 110/70 mmHg. Her lungs are clear, heart sounds are normal, and
there is no lower-extremity edema. Which of the following is the most likely laboratory
study in the acute setting to assist with the diagnosis?
A. Brain natriuretic peptide (BNP)
B. Complete blood count (CBC)
C. Hemoglobin A1c
D. Low-density lipoprotein (LDL)
E. Triglycerides - ANSWER- The ANSWER is B. From IM 02.
Although cardiac causes of chest pain should be considered, it is important to consider
other sources of pain. Anemia may cause chest pain by decreasing oxygen carrying
capacity.
A 66-year-old male presents to his primary care provider with concern for intermittent
chest pain. He describes several episodes a week of pressure under his sternum that
comes on with exertion, lasts for about 5 to 10 minutes and is improved with rest, over
the last two weeks. He notes some shortness of breath with the pain, but denies any
associated diaphoresis, nausea, or jaw pain. He has a history of hypertension and
hyperlipidemia treated with lisinopril, simvastatin, and aspirin. He exercises at a gym for
30 minutes, two to three times per week. Physical examination shows his pulse is 78
beats/minute, respiratory rate is 16 breaths/minute, and blood pressure is 145/80
mmHg. His lungs are clear, heart sounds are normal, and there is no lower-extremity
edema. His electrocardiogram (ECG) is normal. Which of the following is the
mostappropriate next step in his workup? A. Cardiac catheterization
B. Computed tomography (CT) scan
C. Echocardiogram
D. Pharmacologic stress test with imaging
E. Treadmill stress test without imaging - ANSWER- The ANSWER is A. From IM 02.
The patient should proceed directly for a cardiac catheterization. His symptoms meet
the criteria for angina (substernal chest discomfort with a characteristic duration and
features, exertional in nature and relieved with rest or nitroglycerin) and since it is
relatively new and started within the month, it should be considered unstable angina. In
addition, he has considerable risk factors, thus his pretest probability is high for cardiac
disease and cardiac catheterization is recommended.
