NR 511 DIFFERENTIAL DIAGNOSIS AND
PRIMARY CARE PRACTICUM REVIEW
1. A 45-year-old male presents with sudden onset of severe pain, redness, and swelling in the
first metatarsophalangeal joint. A definitive diagnosis of gout is best made by which of the
following?
A. Presence of monosodium urate crystals in synovial fluid
B. Elevated serum uric acid level
C. Characteristic findings on X-ray including ‘punched-out’ erosions
D. Rapid response to colchicine therapy
Answer: A
Conceptual Explanation: While elevated uric acid and imaging findings are suggestive, the
gold standard for diagnosing gout is the identification of monosodium urate crystals in the
synovial fluid of the affected joint under polarized light microscopy.
2. In patients presenting with symptoms of acute rhinosinusitis, which of the following clinical
features most strongly suggests a bacterial rather than viral etiology?
A. Purulent nasal discharge for 3 days
,B. Presence of a low-grade fever (99.8 F)
C. Facial pressure and congestion
D. Symptoms lasting more than 10 days without clinical improvement
Answer: D
Conceptual Explanation: According to IDSA guidelines, acute bacterial rhinosinusitis
(ABRS) is suggested by symptoms lasting >= 10 days, ‘double sickening’ (worsening after
initial improvement), or severe symptoms (high fever and purulent discharge for 3-4 days).
3. According to the GINA guidelines, what is the preferred ‘as-needed’ reliever therapy for
adults with mild (Step 1 or 2) asthma?
A. Low-dose ICS-formoterol combination
B. Low-dose inhaled corticosteroid (ICS) taken daily
C. Short-acting beta-agonist (SABA) alone
D. Oral leukotriene receptor antagonist (LTRA)
Answer: A
Conceptual Explanation: Current GINA guidelines recommend low-dose ICS-formoterol
as the preferred reliever for all steps of asthma management to reduce the risk of severe
exacerbations compared to SABA monotherapy.
, 4. A 68-year-old patient presents with chronic cough and dyspnea. Spirometry reveals an
FEV1/FVC ratio of 0.62. How is this patient classified according to GOLD guidelines?
A. Normal lung function
B. Restrictive lung disease
C. Reversible airway obstruction
D. Obstructive lung disease (COPD)
Answer: D
Conceptual Explanation: A post-bronchodilator FEV1/FVC ratio of less than 0.70 is the
diagnostic criterion for airflow limitation and confirms the diagnosis of COPD according to
GOLD guidelines.
5. Which of the following physical exam findings is most specific for acute cholecystitis?
A. Rovsing’s sign
B. McBurney’s point tenderness
C. Murphy’s sign
D. Psoas sign
Answer: C
Conceptual Explanation: Murphy’s sign (arrest of inspiration on deep palpation of the
right upper quadrant) has a high specificity for acute cholecystitis. Rovsing’s, McBurney’s,
and Psoas signs are associated with appendicitis.
PRIMARY CARE PRACTICUM REVIEW
1. A 45-year-old male presents with sudden onset of severe pain, redness, and swelling in the
first metatarsophalangeal joint. A definitive diagnosis of gout is best made by which of the
following?
A. Presence of monosodium urate crystals in synovial fluid
B. Elevated serum uric acid level
C. Characteristic findings on X-ray including ‘punched-out’ erosions
D. Rapid response to colchicine therapy
Answer: A
Conceptual Explanation: While elevated uric acid and imaging findings are suggestive, the
gold standard for diagnosing gout is the identification of monosodium urate crystals in the
synovial fluid of the affected joint under polarized light microscopy.
2. In patients presenting with symptoms of acute rhinosinusitis, which of the following clinical
features most strongly suggests a bacterial rather than viral etiology?
A. Purulent nasal discharge for 3 days
,B. Presence of a low-grade fever (99.8 F)
C. Facial pressure and congestion
D. Symptoms lasting more than 10 days without clinical improvement
Answer: D
Conceptual Explanation: According to IDSA guidelines, acute bacterial rhinosinusitis
(ABRS) is suggested by symptoms lasting >= 10 days, ‘double sickening’ (worsening after
initial improvement), or severe symptoms (high fever and purulent discharge for 3-4 days).
3. According to the GINA guidelines, what is the preferred ‘as-needed’ reliever therapy for
adults with mild (Step 1 or 2) asthma?
A. Low-dose ICS-formoterol combination
B. Low-dose inhaled corticosteroid (ICS) taken daily
C. Short-acting beta-agonist (SABA) alone
D. Oral leukotriene receptor antagonist (LTRA)
Answer: A
Conceptual Explanation: Current GINA guidelines recommend low-dose ICS-formoterol
as the preferred reliever for all steps of asthma management to reduce the risk of severe
exacerbations compared to SABA monotherapy.
, 4. A 68-year-old patient presents with chronic cough and dyspnea. Spirometry reveals an
FEV1/FVC ratio of 0.62. How is this patient classified according to GOLD guidelines?
A. Normal lung function
B. Restrictive lung disease
C. Reversible airway obstruction
D. Obstructive lung disease (COPD)
Answer: D
Conceptual Explanation: A post-bronchodilator FEV1/FVC ratio of less than 0.70 is the
diagnostic criterion for airflow limitation and confirms the diagnosis of COPD according to
GOLD guidelines.
5. Which of the following physical exam findings is most specific for acute cholecystitis?
A. Rovsing’s sign
B. McBurney’s point tenderness
C. Murphy’s sign
D. Psoas sign
Answer: C
Conceptual Explanation: Murphy’s sign (arrest of inspiration on deep palpation of the
right upper quadrant) has a high specificity for acute cholecystitis. Rovsing’s, McBurney’s,
and Psoas signs are associated with appendicitis.
