NR 576 DIFFERENTIAL DIAGNOSIS ADULT-GERONTOLOGY
PRIMARY CARE MIDTERM 2026/2027 | Questions and
Answers | Grade A 100% Correct | Pass Guaranteed
Domain 1: Clinical Reasoning & Diagnostic Process (15 Questions)
Q1: A 68-year-old male presents with fatigue, weight loss, and night sweats over 3
months. Physical exam reveals cervical lymphadenopathy (2 cm, firm, non-tender) and
splenomegaly. CBC shows WBC 15,000/μL with 60% lymphocytes, Hgb 9.8 g/dL, and
platelets 95,000/μL. Peripheral smear demonstrates smudge cells. What is the most
likely diagnosis?
A. Acute lymphoblastic leukemia
B. Hairy cell leukemia
C. Chronic lymphocytic leukemia [CORRECT]
D. Non-Hodgkin lymphoma
Correct Answer: C
Rationale: Chronic lymphocytic leukemia (CLL) is the most common leukemia in adults
over 65, characterized by lymphocytosis >5,000/μL, smudge cells (Gumprecht shadows)
,on peripheral smear, lymphadenopathy, and autoimmune cytopenias. The B symptoms
(fever, night sweats, weight loss >10% over 6 months) indicate active disease requiring
treatment per iwCLL guidelines. A is incorrect because ALL typically affects younger
patients with blasts on smear and more aggressive presentation. B is incorrect as hairy
cell leukemia presents with pancytopenia, splenomegaly, and hairy cytoplasmic
projections, not smudge cells. D is incorrect because while lymphoma can cause B
symptoms, the peripheral lymphocytosis with smudge cells is pathognomonic for CLL.
Q2: A 72-year-old female with type 2 diabetes and hypertension presents with 2 weeks
of progressive dyspnea, orthopnea, and bilateral lower extremity edema. Vital signs: BP
165/98, HR 92, RR 22, SpO2 91% on room air. Physical exam reveals JVD, bilateral
crackles to mid-lung fields, and 2+ pitting edema. BNP is 850 pg/mL. Chest X-ray shows
cardiomegaly and pulmonary vascular congestion. What is the most appropriate next
diagnostic step?
A. Coronary angiography
B. Echocardiogram [CORRECT]
C. CT pulmonary angiography
D. Right heart catheterization
Correct Answer: B
,Rationale: This patient presents with acute decompensated heart failure (ADHF) with
elevated BNP (>400 pg/mL supports diagnosis). The 2022 AHA/ACC/HFSA Heart
Failure Guidelines recommend transthoracic echocardiogram as the initial diagnostic
test to assess left ventricular ejection fraction (HFrEF vs HFpEF), valvular function, and
wall motion abnormalities. This determines classification and guides therapy. A is
incorrect because coronary angiography is reserved for suspected ACS or ischemic
evaluation after stabilization. C is incorrect as CTPA evaluates for PE, which would
present with pleuritic chest pain, tachypnea, and normal BNP. D is incorrect as right
heart catheterization is reserved for diagnostic uncertainty, cardiogenic shock, or
advanced hemodynamic assessment.
Q3: A 58-year-old male smoker with COPD presents with acute worsening of dyspnea,
increased sputum purulence, and fever to 38.5°C. Arterial blood gas on room air: pH
7.32, PaCO2 58 mmHg, PaO2 52 mmHg, HCO3 30 mEq/L. What acid-base disorder is
present?
A. Acute respiratory acidosis
B. Chronic respiratory acidosis with acute compensation
C. Acute-on-chronic respiratory acidosis [CORRECT]
D. Metabolic alkalosis with respiratory compensation
Correct Answer: C
, Rationale: The ABG demonstrates acute-on-chronic respiratory acidosis. The elevated
PaCO2 (58 mmHg) with increased HCO3 (30 mEq/L) indicates chronic compensation
(expected HCO3 increase is 3.5 mEq/L for every 10 mmHg PaCO2 rise in chronic
conditions; here ~28-31 expected). The pH of 7.32 (acidemia) indicates an acute
decompensation superimposed on chronic CO2 retention from COPD. A is incorrect
because acute respiratory acidosis would show minimal HCO3 elevation (<2-3 mEq/L).
B is incorrect as "chronic with acute compensation" describes a different temporal
pattern. D is incorrect because primary metabolic alkalosis would demonstrate
alkalemia, not acidemia.
Q4: A 65-year-old female presents with polyuria, polydipsia, and blurred vision. Random
glucose is 320 mg/dL. Which laboratory finding distinguishes type 1 from type 2
diabetes in this patient?
A. Fasting C-peptide level
B. Islet cell antibody testing
C. Presence of ketonuria
D. Hemoglobin A1c level [CORRECT]
Correct Answer: D
Rationale: Trick question testing clinical reasoning. D (Hemoglobin A1c) is the correct
answer because it is NOT useful for distinguishing type 1 from type 2 diabetes—it only
PRIMARY CARE MIDTERM 2026/2027 | Questions and
Answers | Grade A 100% Correct | Pass Guaranteed
Domain 1: Clinical Reasoning & Diagnostic Process (15 Questions)
Q1: A 68-year-old male presents with fatigue, weight loss, and night sweats over 3
months. Physical exam reveals cervical lymphadenopathy (2 cm, firm, non-tender) and
splenomegaly. CBC shows WBC 15,000/μL with 60% lymphocytes, Hgb 9.8 g/dL, and
platelets 95,000/μL. Peripheral smear demonstrates smudge cells. What is the most
likely diagnosis?
A. Acute lymphoblastic leukemia
B. Hairy cell leukemia
C. Chronic lymphocytic leukemia [CORRECT]
D. Non-Hodgkin lymphoma
Correct Answer: C
Rationale: Chronic lymphocytic leukemia (CLL) is the most common leukemia in adults
over 65, characterized by lymphocytosis >5,000/μL, smudge cells (Gumprecht shadows)
,on peripheral smear, lymphadenopathy, and autoimmune cytopenias. The B symptoms
(fever, night sweats, weight loss >10% over 6 months) indicate active disease requiring
treatment per iwCLL guidelines. A is incorrect because ALL typically affects younger
patients with blasts on smear and more aggressive presentation. B is incorrect as hairy
cell leukemia presents with pancytopenia, splenomegaly, and hairy cytoplasmic
projections, not smudge cells. D is incorrect because while lymphoma can cause B
symptoms, the peripheral lymphocytosis with smudge cells is pathognomonic for CLL.
Q2: A 72-year-old female with type 2 diabetes and hypertension presents with 2 weeks
of progressive dyspnea, orthopnea, and bilateral lower extremity edema. Vital signs: BP
165/98, HR 92, RR 22, SpO2 91% on room air. Physical exam reveals JVD, bilateral
crackles to mid-lung fields, and 2+ pitting edema. BNP is 850 pg/mL. Chest X-ray shows
cardiomegaly and pulmonary vascular congestion. What is the most appropriate next
diagnostic step?
A. Coronary angiography
B. Echocardiogram [CORRECT]
C. CT pulmonary angiography
D. Right heart catheterization
Correct Answer: B
,Rationale: This patient presents with acute decompensated heart failure (ADHF) with
elevated BNP (>400 pg/mL supports diagnosis). The 2022 AHA/ACC/HFSA Heart
Failure Guidelines recommend transthoracic echocardiogram as the initial diagnostic
test to assess left ventricular ejection fraction (HFrEF vs HFpEF), valvular function, and
wall motion abnormalities. This determines classification and guides therapy. A is
incorrect because coronary angiography is reserved for suspected ACS or ischemic
evaluation after stabilization. C is incorrect as CTPA evaluates for PE, which would
present with pleuritic chest pain, tachypnea, and normal BNP. D is incorrect as right
heart catheterization is reserved for diagnostic uncertainty, cardiogenic shock, or
advanced hemodynamic assessment.
Q3: A 58-year-old male smoker with COPD presents with acute worsening of dyspnea,
increased sputum purulence, and fever to 38.5°C. Arterial blood gas on room air: pH
7.32, PaCO2 58 mmHg, PaO2 52 mmHg, HCO3 30 mEq/L. What acid-base disorder is
present?
A. Acute respiratory acidosis
B. Chronic respiratory acidosis with acute compensation
C. Acute-on-chronic respiratory acidosis [CORRECT]
D. Metabolic alkalosis with respiratory compensation
Correct Answer: C
, Rationale: The ABG demonstrates acute-on-chronic respiratory acidosis. The elevated
PaCO2 (58 mmHg) with increased HCO3 (30 mEq/L) indicates chronic compensation
(expected HCO3 increase is 3.5 mEq/L for every 10 mmHg PaCO2 rise in chronic
conditions; here ~28-31 expected). The pH of 7.32 (acidemia) indicates an acute
decompensation superimposed on chronic CO2 retention from COPD. A is incorrect
because acute respiratory acidosis would show minimal HCO3 elevation (<2-3 mEq/L).
B is incorrect as "chronic with acute compensation" describes a different temporal
pattern. D is incorrect because primary metabolic alkalosis would demonstrate
alkalemia, not acidemia.
Q4: A 65-year-old female presents with polyuria, polydipsia, and blurred vision. Random
glucose is 320 mg/dL. Which laboratory finding distinguishes type 1 from type 2
diabetes in this patient?
A. Fasting C-peptide level
B. Islet cell antibody testing
C. Presence of ketonuria
D. Hemoglobin A1c level [CORRECT]
Correct Answer: D
Rationale: Trick question testing clinical reasoning. D (Hemoglobin A1c) is the correct
answer because it is NOT useful for distinguishing type 1 from type 2 diabetes—it only
