NR-511 – Differential Diagnosis & Primary Care
Advanced Primary Care Study Guide, Clinical
Diagnosis, Treatment Planning, Patient
Assessment, and Examination Success
Q1. A 45-year-old male presents with chest pain. Which of the following findings
is MOST concerning for an acute myocardial infarction (MI)?
A) Sharp, pleuritic pain that worsens with inspiration
B) Pain that radiates to the left arm and is associated with diaphoresis and
nausea
C) Pain that is reproducible with palpation of the chest wall
D) Pain that improves with leaning forward
Answer: B — Pain that radiates to the left arm and is associated with
diaphoresis and nausea
Rationale: Pain radiating to the left arm (or jaw) associated
with diaphoresis and nausea is a classic presentation of acute myocardial
infarction (MI) . Pain that is pleuritic (worsens with inspiration) suggests
pericarditis or pleuritis. Pain reproducible with palpation suggests musculoskeletal
pain (costochondritis). Pain that improves with leaning forward is classic for
pericarditis. The presence of diaphoresis and nausea with chest pain significantly
increases the suspicion for MI and requires immediate evaluation with ECG and
troponin.
Q2. A 28-year-old female presents with fatigue, weight gain, cold intolerance, and
constipation. Which of the following is the most likely diagnosis?
A) Hyperthyroidism
B) Hypothyroidism
C) Anemia
D) Depression
Answer: B — Hypothyroidism
,Rationale: The classic symptoms of hypothyroidism include fatigue, weight
gain, cold intolerance, constipation, dry skin, hair loss, and bradycardia.
Hyperthyroidism presents with weight loss, heat intolerance, and diarrhea. Anemia
can cause fatigue but not typically weight gain and cold intolerance. Depression
can cause fatigue and weight changes but is less likely to cause the classic
constellation of symptoms seen in hypothyroidism. The most common cause of
hypothyroidism in the U.S. is Hashimoto's thyroiditis.
Q3. A 55-year-old male with a history of hypertension and diabetes presents with
sudden onset of severe headache, nausea, and vomiting. Blood pressure is 220/120
mmHg. What is the priority intervention?
A) Oral antihypertensive medication
B) Immediate IV antihypertensive therapy and emergent evaluation
C) Observation and reassess in 1 hour
D) Discharge with follow-up
Answer: B — Immediate IV antihypertensive therapy and emergent
evaluation
Rationale: This patient is presenting with hypertensive emergency (severe
hypertension with acute end-organ damage, as evidenced by the severe headache).
The priority is immediate IV antihypertensive therapy to reduce blood pressure
gradually (not too rapidly) and emergent evaluation for stroke, encephalopathy, or
other end-organ damage. Oral antihypertensives are not appropriate for
hypertensive emergencies. Observation without intervention is unsafe.
Hypertensive urgency (no end-organ damage) can be managed with oral
medications, but this patient has signs of end-organ damage (severe headache,
nausea, vomiting).
Q4. A 34-year-old female presents with dysuria, urinary frequency, and suprapubic
pain. She reports no vaginal discharge. Urinalysis shows leukocyte esterase and
nitrites positive. What is the most likely diagnosis?
A) Vaginitis
B) Acute cystitis (uncomplicated UTI)
,C) Pyelonephritis
D) Interstitial cystitis
Answer: B — Acute cystitis (uncomplicated UTI)
Rationale: The classic symptoms of acute cystitis (uncomplicated urinary tract
infection) include dysuria, urinary frequency, suprapubic pain, and hematuria.
The absence of vaginal discharge and the positive urinalysis (leukocyte esterase
and nitrites) support the diagnosis. Pyelonephritis would present with fever, chills,
and flank pain. Vaginitis would present with vaginal discharge and itching.
Interstitial cystitis is a chronic condition without infection. Uncomplicated UTI is
commonly caused by Escherichia coli.
Q5. A 62-year-old female presents with right upper quadrant pain, nausea, and
vomiting after a fatty meal. Murphy's sign is positive. What is the most likely
diagnosis?
A) Peptic ulcer disease
B) Acute cholecystitis
C) Pancreatitis
D) Gastroenteritis
Answer: B — Acute cholecystitis
Rationale: The classic presentation of acute cholecystitis includes right upper
quadrant pain that may radiate to the right shoulder or back, nausea, vomiting,
and pain after a fatty meal. Murphy's sign (pain on inspiration with palpation of
the right upper quadrant) is a classic finding. Peptic ulcer disease typically presents
with epigastric pain. Pancreatitis presents with epigastric pain radiating to the back.
Gastroenteritis presents with diffuse abdominal pain and diarrhea. Ultrasound is
the imaging modality of choice to confirm cholecystitis.
Q6. A 25-year-old male presents with a painful, swollen left knee after a basketball
game. He reports that the knee "gave out" and he heard a "pop." On examination,
the knee is swollen and tender, with a positive anterior drawer test. What is the
most likely diagnosis?
, A) Patellar fracture
B) Anterior cruciate ligament (ACL) tear
C) Medial collateral ligament (MCL) sprain
D) Meniscal tear
Answer: B — Anterior cruciate ligament (ACL) tear
Rationale: The classic mechanism for an ACL tear is a non-contact injury with a
"pop" sound, knee giving way, and immediate swelling (hemarthrosis). A positive
anterior drawer test (anterior translation of the tibia on the femur) indicates ACL
insufficiency. A patellar fracture would have focal pain over the patella and
inability to extend the knee. An MCL sprain causes pain on the medial knee and a
positive valgus stress test. A meniscal tear causes joint line pain and a positive
McMurray test.
Q7. A 50-year-old male presents with a rash on his trunk that is red, scaly, and has
a silvery appearance. He reports that it has been present for several months and is
itchy. What is the most likely diagnosis?
A) Eczema
B) Psoriasis
C) Tinea corporis
D) Contact dermatitis
Answer: B — Psoriasis
Rationale: Psoriasis is characterized by well-demarcated, red, scaly
plaques with a silvery scale. It commonly affects the elbows, knees, scalp, and
trunk. Psoriasis is a chronic autoimmune condition that may be associated with
psoriatic arthritis. Eczema (atopic dermatitis) presents with dry, itchy,
erythematous patches, often in flexural areas. Tinea corporis (ringworm) presents
with annular, scaly lesions with central clearing. Contact dermatitis is a localized
reaction to an allergen or irritant.
Q8. A 72-year-old male presents with progressive shortness of breath, orthopnea,
and bilateral lower extremity edema. He has a history of hypertension. On
examination, he has jugular venous distention (JVD) and crackles in the lung
bases. What is the most likely diagnosis?
Advanced Primary Care Study Guide, Clinical
Diagnosis, Treatment Planning, Patient
Assessment, and Examination Success
Q1. A 45-year-old male presents with chest pain. Which of the following findings
is MOST concerning for an acute myocardial infarction (MI)?
A) Sharp, pleuritic pain that worsens with inspiration
B) Pain that radiates to the left arm and is associated with diaphoresis and
nausea
C) Pain that is reproducible with palpation of the chest wall
D) Pain that improves with leaning forward
Answer: B — Pain that radiates to the left arm and is associated with
diaphoresis and nausea
Rationale: Pain radiating to the left arm (or jaw) associated
with diaphoresis and nausea is a classic presentation of acute myocardial
infarction (MI) . Pain that is pleuritic (worsens with inspiration) suggests
pericarditis or pleuritis. Pain reproducible with palpation suggests musculoskeletal
pain (costochondritis). Pain that improves with leaning forward is classic for
pericarditis. The presence of diaphoresis and nausea with chest pain significantly
increases the suspicion for MI and requires immediate evaluation with ECG and
troponin.
Q2. A 28-year-old female presents with fatigue, weight gain, cold intolerance, and
constipation. Which of the following is the most likely diagnosis?
A) Hyperthyroidism
B) Hypothyroidism
C) Anemia
D) Depression
Answer: B — Hypothyroidism
,Rationale: The classic symptoms of hypothyroidism include fatigue, weight
gain, cold intolerance, constipation, dry skin, hair loss, and bradycardia.
Hyperthyroidism presents with weight loss, heat intolerance, and diarrhea. Anemia
can cause fatigue but not typically weight gain and cold intolerance. Depression
can cause fatigue and weight changes but is less likely to cause the classic
constellation of symptoms seen in hypothyroidism. The most common cause of
hypothyroidism in the U.S. is Hashimoto's thyroiditis.
Q3. A 55-year-old male with a history of hypertension and diabetes presents with
sudden onset of severe headache, nausea, and vomiting. Blood pressure is 220/120
mmHg. What is the priority intervention?
A) Oral antihypertensive medication
B) Immediate IV antihypertensive therapy and emergent evaluation
C) Observation and reassess in 1 hour
D) Discharge with follow-up
Answer: B — Immediate IV antihypertensive therapy and emergent
evaluation
Rationale: This patient is presenting with hypertensive emergency (severe
hypertension with acute end-organ damage, as evidenced by the severe headache).
The priority is immediate IV antihypertensive therapy to reduce blood pressure
gradually (not too rapidly) and emergent evaluation for stroke, encephalopathy, or
other end-organ damage. Oral antihypertensives are not appropriate for
hypertensive emergencies. Observation without intervention is unsafe.
Hypertensive urgency (no end-organ damage) can be managed with oral
medications, but this patient has signs of end-organ damage (severe headache,
nausea, vomiting).
Q4. A 34-year-old female presents with dysuria, urinary frequency, and suprapubic
pain. She reports no vaginal discharge. Urinalysis shows leukocyte esterase and
nitrites positive. What is the most likely diagnosis?
A) Vaginitis
B) Acute cystitis (uncomplicated UTI)
,C) Pyelonephritis
D) Interstitial cystitis
Answer: B — Acute cystitis (uncomplicated UTI)
Rationale: The classic symptoms of acute cystitis (uncomplicated urinary tract
infection) include dysuria, urinary frequency, suprapubic pain, and hematuria.
The absence of vaginal discharge and the positive urinalysis (leukocyte esterase
and nitrites) support the diagnosis. Pyelonephritis would present with fever, chills,
and flank pain. Vaginitis would present with vaginal discharge and itching.
Interstitial cystitis is a chronic condition without infection. Uncomplicated UTI is
commonly caused by Escherichia coli.
Q5. A 62-year-old female presents with right upper quadrant pain, nausea, and
vomiting after a fatty meal. Murphy's sign is positive. What is the most likely
diagnosis?
A) Peptic ulcer disease
B) Acute cholecystitis
C) Pancreatitis
D) Gastroenteritis
Answer: B — Acute cholecystitis
Rationale: The classic presentation of acute cholecystitis includes right upper
quadrant pain that may radiate to the right shoulder or back, nausea, vomiting,
and pain after a fatty meal. Murphy's sign (pain on inspiration with palpation of
the right upper quadrant) is a classic finding. Peptic ulcer disease typically presents
with epigastric pain. Pancreatitis presents with epigastric pain radiating to the back.
Gastroenteritis presents with diffuse abdominal pain and diarrhea. Ultrasound is
the imaging modality of choice to confirm cholecystitis.
Q6. A 25-year-old male presents with a painful, swollen left knee after a basketball
game. He reports that the knee "gave out" and he heard a "pop." On examination,
the knee is swollen and tender, with a positive anterior drawer test. What is the
most likely diagnosis?
, A) Patellar fracture
B) Anterior cruciate ligament (ACL) tear
C) Medial collateral ligament (MCL) sprain
D) Meniscal tear
Answer: B — Anterior cruciate ligament (ACL) tear
Rationale: The classic mechanism for an ACL tear is a non-contact injury with a
"pop" sound, knee giving way, and immediate swelling (hemarthrosis). A positive
anterior drawer test (anterior translation of the tibia on the femur) indicates ACL
insufficiency. A patellar fracture would have focal pain over the patella and
inability to extend the knee. An MCL sprain causes pain on the medial knee and a
positive valgus stress test. A meniscal tear causes joint line pain and a positive
McMurray test.
Q7. A 50-year-old male presents with a rash on his trunk that is red, scaly, and has
a silvery appearance. He reports that it has been present for several months and is
itchy. What is the most likely diagnosis?
A) Eczema
B) Psoriasis
C) Tinea corporis
D) Contact dermatitis
Answer: B — Psoriasis
Rationale: Psoriasis is characterized by well-demarcated, red, scaly
plaques with a silvery scale. It commonly affects the elbows, knees, scalp, and
trunk. Psoriasis is a chronic autoimmune condition that may be associated with
psoriatic arthritis. Eczema (atopic dermatitis) presents with dry, itchy,
erythematous patches, often in flexural areas. Tinea corporis (ringworm) presents
with annular, scaly lesions with central clearing. Contact dermatitis is a localized
reaction to an allergen or irritant.
Q8. A 72-year-old male presents with progressive shortness of breath, orthopnea,
and bilateral lower extremity edema. He has a history of hypertension. On
examination, he has jugular venous distention (JVD) and crackles in the lung
bases. What is the most likely diagnosis?
