NR569 DIFFERENTIAL DIAGNOSIS IN ACUTE
CARE MIDTERM| WITH DETAILED
(150)QUESTIONS & CORRECT EXPLAINED
ANSEWERS|LATEST UPDATE 2026 GRADED A+–
CHAMBERLAIN
1. A 45-year-old patient with a history of hypertension and type 2 diabetes presents with severe,
tearing chest pain that radiates to the back. Blood pressure is 210/120 mm Hg in the right arm and
180/100 mm Hg in the left arm. A chest radiograph shows a widened mediastinum. Which of the
following diagnostic findings would most definitively confirm the suspected diagnosis?
A. Elevated D-dimer
B. Pericardial effusion on echocardiography
C. Intimal flap on transesophageal echocardiography
D. ST-segment elevation in leads V1-V4
Answer: C
Rationale: The presentation is classic for acute aortic dissection. The intimal flap is the definitive
diagnostic finding on imaging such as TEE, CT angiography, or MRI. Elevated D-dimer is nonspecific
and not diagnostic. Pericardial effusion may occur with dissection but is not definitive. ST elevation
suggests myocardial infarction, which can mimic dissection but is not the primary diagnosis here.
2. A 60-year-old patient is brought to the emergency department with acute onset of confusion,
dysarthria, and right-sided weakness. Symptoms began 2 hours ago. Blood pressure is 185/110 mm
Hg. CT head without contrast shows no hemorrhage. Which of the following is the most
appropriate next step in management?
A. Administer intravenous alteplase immediately
B. Administer aspirin 325 mg orally
C. Lower blood pressure to <180/105 mm Hg with intravenous antihypertensives and then give alteplase
D. Consult interventional radiology for mechanical thrombectomy without alteplase
Answer: C
Rationale: The patient presents with acute ischemic stroke within the window for alteplase (3 hours from
symptom onset). However, blood pressure must be lowered to <185/110 mm Hg before administering
alteplase per AHA/ASA guidelines. Aspirin is not given within 24 hours of thrombolysis. Mechanical
thrombectomy may be considered, but alteplase is still indicated if eligible.
Page 1
,3. A 55-year-old patient with a history of COPD presents with acute dyspnea, pleuritic chest pain,
and hemoptysis. Vital signs: HR 110, BP 130/80, RR 24, O2 sat 88% on room air. ECG shows sinus
tachycardia with S1Q3T3 pattern. Which of the following laboratory findings would most strongly
support the diagnosis?
A. Elevated troponin I
B. Positive D-dimer
C. Decreased PaO2 on arterial blood gas
D. Elevated brain natriuretic peptide
Answer: B
Rationale: The clinical picture (dyspnea, pleuritic pain, hemoptysis, tachycardia, S1Q3T3) suggests
pulmonary embolism. A positive D-dimer supports the diagnosis, but given the high pretest probability,
a CT pulmonary angiogram would be definitive. Elevated troponin may indicate right heart strain but is
not specific. Decreased PaO2 is common but not diagnostic. BNP elevation is more indicative of heart
failure.
4. A 50-year-old patient with cirrhosis presents with acute onset of confusion, asterixis, and
jaundice. Laboratory studies show elevated ammonia, prolonged prothrombin time, and bilirubin
4.5 mg/dL. Which of the following is the most likely precipitating factor for this presentation?
A. Spontaneous bacterial peritonitis
B. Upper gastrointestinal bleeding
C. Hepatocellular carcinoma
D. Acute alcoholic hepatitis
Answer: B
Rationale: The patient has hepatic encephalopathy. Upper GI bleeding is a common precipitant due to
increased protein load from blood in the gut. SBP, infection, and electrolyte disturbances are also
triggers, but GI bleeding is the most likely given the presentation. Hepatocellular carcinoma may cause
decompensation but is less acute. Alcoholic hepatitis could be a factor but bleeding is a more direct
cause of encephalopathy.
5. A 65-year-old patient with a history of atrial fibrillation on warfarin presents with acute onset of
severe abdominal pain and vomiting. CT abdomen shows thickening of the small bowel wall with
pneumatosis intestinalis. Which of the following is the most likely diagnosis?
A. Acute mesenteric ischemia
B. Small bowel obstruction
C. Diverticulitis with perforation
D. Inflammatory bowel disease flare
Answer: A
Rationale: The patient has atrial fibrillation (risk factor for emboli), acute severe abdominal pain, and
CT findings of bowel wall thickening with pneumatosis (air in bowel wall), which is indicative of
mesenteric ischemia. Small bowel obstruction typically shows dilated loops with air-fluid levels.
Diverticulitis usually presents with left lower quadrant pain and fever. IBD flare is more chronic and
would not typically cause pneumatosis.
Page 2
,6. A 70-year-old patient with a history of hypertension and chronic kidney disease (stage 3)
presents with acute onset of shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea.
Crackles are heard halfway up both lung fields. Jugular venous pressure is elevated. Which of the
following medications should be avoided in the acute management of this patient?
A. Intravenous furosemide
B. Intravenous nitroglycerin
C. Intravenous morphine
D. Intravenous metoprolol
Answer: D
Rationale: The patient presents with acute decompensated heart failure with pulmonary edema.
Intravenous beta-blockers (e.g., metoprolol) are contraindicated in acute decompensation as they can
reduce cardiac output and worsen heart failure. Furosemide, nitroglycerin, and morphine are standard
therapies for preload reduction and symptom relief.
7. A 40-year-old patient with no significant medical history presents with acute onset of severe
headache, neck stiffness, and photophobia. CSF analysis reveals: WBC 500 cells/µL (80%
neutrophils), glucose 30 mg/dL (serum glucose 100 mg/dL), protein 150 mg/dL. Gram stain shows
gram-negative diplococci. Which of the following is the most appropriate empiric antibiotic
therapy?
A. Ceftriaxone plus vancomycin
B. Ampicillin plus gentamicin
C. Ceftazidime plus acyclovir
D. Penicillin G alone
Answer: A
Rationale: The CSF findings (elevated WBC with neutrophils, low glucose, high protein) and
gram-negative diplococci are classic for Neisseria meningitidis. Empiric therapy for bacterial
meningitis should include ceftriaxone (covers N. meningitidis and S. pneumoniae) plus vancomycin (for
resistant S. pneumoniae) until culture results are available. Ampicillin/gentamicin is for Listeria.
Ceftazidime/acyclovir is for HSV encephalitis. Penicillin G alone is insufficient for empiric coverage.
8. A 55-year-old patient with a history of type 2 diabetes presents with acute onset of severe right
upper quadrant pain, fever, and jaundice. Ultrasound shows a dilated common bile duct and
gallstones. ERCP is performed and reveals purulent bile. Which of the following is the most likely
diagnosis?
A. Acute cholecystitis
B. Acute cholangitis
C. Acute pancreatitis
D. Hepatic abscess
Answer: B
Rationale: The triad of RUQ pain, fever, and jaundice (Charcot's triad) plus purulent bile at ERCP is
diagnostic of acute cholangitis. Acute cholecystitis typically presents with pain and fever but not
jaundice unless there is obstruction. Acute pancreatitis usually presents with epigastric pain radiating to
the back. Hepatic abscess may cause fever and RUQ pain but not purulent bile in the common bile duct.
Page 3
, 9. A 30-year-old patient with a history of intravenous drug use presents with fever, chills, and a
new holosystolic murmur. Blood cultures grow Staphylococcus aureus. Which of the following is
the most likely complication?
A. Acute mitral regurgitation
B. Pericardial effusion
C. Myocardial abscess
D. Aortic valve vegetation
Answer: D
Rationale: IV drug users are at high risk for infective endocarditis, typically affecting the tricuspid valve,
but also aortic and mitral. Staphylococcus aureus is a common cause. A new holosystolic murmur
suggests valvular involvement, and vegetations are characteristic. Acute mitral regurgitation is a
consequence but not the primary complication. Pericardial effusion and myocardial abscess are less
common.
10. A 60-year-old patient with a history of hypertension presents with acute onset of severe
epigastric pain radiating to the back, nausea, and vomiting. Serum lipase is 1200 U/L. CT abdomen
shows peripancreatic fat stranding and a fluid collection in the lesser sac. Which of the following is
the most important predictor of mortality in this patient?
A. Age >55 years
B. Serum creatinine >2 mg/dL
C. Body mass index >30 kg/m²
D. Pleural effusion on chest radiograph
Answer: B
Rationale: This patient has acute pancreatitis. The Ranson criteria and other scoring systems identify
renal failure (creatinine >2 mg/dL) as a strong predictor of mortality. Age >55 is a factor but not the
most important. Obesity (BMI >30) is associated with severity but not as strong as renal failure. Pleural
effusion indicates severe disease but is not an independent predictor of mortality.
11. A patient presents with acute onset of severe epigastric pain radiating to the back, nausea, and
vomiting. Serum lipase is elevated three times the upper limit. Contrast-enhanced CT shows
peripancreatic fat stranding without necrosis. Which of the following is the most appropriate
initial step in management to reduce morbidity?
A. Immediate endoscopic retrograde cholangiopancreatography (ERCP)
B. Aggressive intravenous fluid resuscitation with lactated Ringer's solution
C. Empiric antibiotic therapy with imipenem-cilastatin
D. Parenteral nutrition within 24 hours
Answer: B
Rationale: In acute pancreatitis, aggressive fluid resuscitation within the first 24 hours reduces mortality
and morbidity. ERCP is indicated only if cholangitis or biliary obstruction is present. Antibiotics are not
routinely recommended unless infected necrosis develops. Enteral nutrition is preferred over parenteral;
parenteral nutrition is avoided early due to risk of line infections and gut barrier dysfunction.
Page 4
CARE MIDTERM| WITH DETAILED
(150)QUESTIONS & CORRECT EXPLAINED
ANSEWERS|LATEST UPDATE 2026 GRADED A+–
CHAMBERLAIN
1. A 45-year-old patient with a history of hypertension and type 2 diabetes presents with severe,
tearing chest pain that radiates to the back. Blood pressure is 210/120 mm Hg in the right arm and
180/100 mm Hg in the left arm. A chest radiograph shows a widened mediastinum. Which of the
following diagnostic findings would most definitively confirm the suspected diagnosis?
A. Elevated D-dimer
B. Pericardial effusion on echocardiography
C. Intimal flap on transesophageal echocardiography
D. ST-segment elevation in leads V1-V4
Answer: C
Rationale: The presentation is classic for acute aortic dissection. The intimal flap is the definitive
diagnostic finding on imaging such as TEE, CT angiography, or MRI. Elevated D-dimer is nonspecific
and not diagnostic. Pericardial effusion may occur with dissection but is not definitive. ST elevation
suggests myocardial infarction, which can mimic dissection but is not the primary diagnosis here.
2. A 60-year-old patient is brought to the emergency department with acute onset of confusion,
dysarthria, and right-sided weakness. Symptoms began 2 hours ago. Blood pressure is 185/110 mm
Hg. CT head without contrast shows no hemorrhage. Which of the following is the most
appropriate next step in management?
A. Administer intravenous alteplase immediately
B. Administer aspirin 325 mg orally
C. Lower blood pressure to <180/105 mm Hg with intravenous antihypertensives and then give alteplase
D. Consult interventional radiology for mechanical thrombectomy without alteplase
Answer: C
Rationale: The patient presents with acute ischemic stroke within the window for alteplase (3 hours from
symptom onset). However, blood pressure must be lowered to <185/110 mm Hg before administering
alteplase per AHA/ASA guidelines. Aspirin is not given within 24 hours of thrombolysis. Mechanical
thrombectomy may be considered, but alteplase is still indicated if eligible.
Page 1
,3. A 55-year-old patient with a history of COPD presents with acute dyspnea, pleuritic chest pain,
and hemoptysis. Vital signs: HR 110, BP 130/80, RR 24, O2 sat 88% on room air. ECG shows sinus
tachycardia with S1Q3T3 pattern. Which of the following laboratory findings would most strongly
support the diagnosis?
A. Elevated troponin I
B. Positive D-dimer
C. Decreased PaO2 on arterial blood gas
D. Elevated brain natriuretic peptide
Answer: B
Rationale: The clinical picture (dyspnea, pleuritic pain, hemoptysis, tachycardia, S1Q3T3) suggests
pulmonary embolism. A positive D-dimer supports the diagnosis, but given the high pretest probability,
a CT pulmonary angiogram would be definitive. Elevated troponin may indicate right heart strain but is
not specific. Decreased PaO2 is common but not diagnostic. BNP elevation is more indicative of heart
failure.
4. A 50-year-old patient with cirrhosis presents with acute onset of confusion, asterixis, and
jaundice. Laboratory studies show elevated ammonia, prolonged prothrombin time, and bilirubin
4.5 mg/dL. Which of the following is the most likely precipitating factor for this presentation?
A. Spontaneous bacterial peritonitis
B. Upper gastrointestinal bleeding
C. Hepatocellular carcinoma
D. Acute alcoholic hepatitis
Answer: B
Rationale: The patient has hepatic encephalopathy. Upper GI bleeding is a common precipitant due to
increased protein load from blood in the gut. SBP, infection, and electrolyte disturbances are also
triggers, but GI bleeding is the most likely given the presentation. Hepatocellular carcinoma may cause
decompensation but is less acute. Alcoholic hepatitis could be a factor but bleeding is a more direct
cause of encephalopathy.
5. A 65-year-old patient with a history of atrial fibrillation on warfarin presents with acute onset of
severe abdominal pain and vomiting. CT abdomen shows thickening of the small bowel wall with
pneumatosis intestinalis. Which of the following is the most likely diagnosis?
A. Acute mesenteric ischemia
B. Small bowel obstruction
C. Diverticulitis with perforation
D. Inflammatory bowel disease flare
Answer: A
Rationale: The patient has atrial fibrillation (risk factor for emboli), acute severe abdominal pain, and
CT findings of bowel wall thickening with pneumatosis (air in bowel wall), which is indicative of
mesenteric ischemia. Small bowel obstruction typically shows dilated loops with air-fluid levels.
Diverticulitis usually presents with left lower quadrant pain and fever. IBD flare is more chronic and
would not typically cause pneumatosis.
Page 2
,6. A 70-year-old patient with a history of hypertension and chronic kidney disease (stage 3)
presents with acute onset of shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea.
Crackles are heard halfway up both lung fields. Jugular venous pressure is elevated. Which of the
following medications should be avoided in the acute management of this patient?
A. Intravenous furosemide
B. Intravenous nitroglycerin
C. Intravenous morphine
D. Intravenous metoprolol
Answer: D
Rationale: The patient presents with acute decompensated heart failure with pulmonary edema.
Intravenous beta-blockers (e.g., metoprolol) are contraindicated in acute decompensation as they can
reduce cardiac output and worsen heart failure. Furosemide, nitroglycerin, and morphine are standard
therapies for preload reduction and symptom relief.
7. A 40-year-old patient with no significant medical history presents with acute onset of severe
headache, neck stiffness, and photophobia. CSF analysis reveals: WBC 500 cells/µL (80%
neutrophils), glucose 30 mg/dL (serum glucose 100 mg/dL), protein 150 mg/dL. Gram stain shows
gram-negative diplococci. Which of the following is the most appropriate empiric antibiotic
therapy?
A. Ceftriaxone plus vancomycin
B. Ampicillin plus gentamicin
C. Ceftazidime plus acyclovir
D. Penicillin G alone
Answer: A
Rationale: The CSF findings (elevated WBC with neutrophils, low glucose, high protein) and
gram-negative diplococci are classic for Neisseria meningitidis. Empiric therapy for bacterial
meningitis should include ceftriaxone (covers N. meningitidis and S. pneumoniae) plus vancomycin (for
resistant S. pneumoniae) until culture results are available. Ampicillin/gentamicin is for Listeria.
Ceftazidime/acyclovir is for HSV encephalitis. Penicillin G alone is insufficient for empiric coverage.
8. A 55-year-old patient with a history of type 2 diabetes presents with acute onset of severe right
upper quadrant pain, fever, and jaundice. Ultrasound shows a dilated common bile duct and
gallstones. ERCP is performed and reveals purulent bile. Which of the following is the most likely
diagnosis?
A. Acute cholecystitis
B. Acute cholangitis
C. Acute pancreatitis
D. Hepatic abscess
Answer: B
Rationale: The triad of RUQ pain, fever, and jaundice (Charcot's triad) plus purulent bile at ERCP is
diagnostic of acute cholangitis. Acute cholecystitis typically presents with pain and fever but not
jaundice unless there is obstruction. Acute pancreatitis usually presents with epigastric pain radiating to
the back. Hepatic abscess may cause fever and RUQ pain but not purulent bile in the common bile duct.
Page 3
, 9. A 30-year-old patient with a history of intravenous drug use presents with fever, chills, and a
new holosystolic murmur. Blood cultures grow Staphylococcus aureus. Which of the following is
the most likely complication?
A. Acute mitral regurgitation
B. Pericardial effusion
C. Myocardial abscess
D. Aortic valve vegetation
Answer: D
Rationale: IV drug users are at high risk for infective endocarditis, typically affecting the tricuspid valve,
but also aortic and mitral. Staphylococcus aureus is a common cause. A new holosystolic murmur
suggests valvular involvement, and vegetations are characteristic. Acute mitral regurgitation is a
consequence but not the primary complication. Pericardial effusion and myocardial abscess are less
common.
10. A 60-year-old patient with a history of hypertension presents with acute onset of severe
epigastric pain radiating to the back, nausea, and vomiting. Serum lipase is 1200 U/L. CT abdomen
shows peripancreatic fat stranding and a fluid collection in the lesser sac. Which of the following is
the most important predictor of mortality in this patient?
A. Age >55 years
B. Serum creatinine >2 mg/dL
C. Body mass index >30 kg/m²
D. Pleural effusion on chest radiograph
Answer: B
Rationale: This patient has acute pancreatitis. The Ranson criteria and other scoring systems identify
renal failure (creatinine >2 mg/dL) as a strong predictor of mortality. Age >55 is a factor but not the
most important. Obesity (BMI >30) is associated with severity but not as strong as renal failure. Pleural
effusion indicates severe disease but is not an independent predictor of mortality.
11. A patient presents with acute onset of severe epigastric pain radiating to the back, nausea, and
vomiting. Serum lipase is elevated three times the upper limit. Contrast-enhanced CT shows
peripancreatic fat stranding without necrosis. Which of the following is the most appropriate
initial step in management to reduce morbidity?
A. Immediate endoscopic retrograde cholangiopancreatography (ERCP)
B. Aggressive intravenous fluid resuscitation with lactated Ringer's solution
C. Empiric antibiotic therapy with imipenem-cilastatin
D. Parenteral nutrition within 24 hours
Answer: B
Rationale: In acute pancreatitis, aggressive fluid resuscitation within the first 24 hours reduces mortality
and morbidity. ERCP is indicated only if cholangitis or biliary obstruction is present. Antibiotics are not
routinely recommended unless infected necrosis develops. Enteral nutrition is preferred over parenteral;
parenteral nutrition is avoided early due to risk of line infections and gut barrier dysfunction.
Page 4
