NR 511 Differential Diagnosis and Primary Care
Practicum Final – Chamberlain University
SECTION 1: FOUNDATIONS OF DIAGNOSTIC REASONING
Questions 1–10
Question 1
A 52-year-old female presents with complaints of fatigue, weight gain, and cold
intolerance over the past 4 months. On physical examination, you note dry skin,
bradycardia, and a non-tender goiter. Initial laboratory testing reveals an elevated
TSH and low free T4. Which of the following represents the BEST next step in
diagnostic reasoning?
A. Order a thyroid ultrasound to evaluate for nodules
B. Begin empiric levothyroxine therapy and recheck TSH in 6 weeks
C. Order anti-thyroid peroxidase antibodies to confirm the diagnosis
D. Order a thyroid scan to assess for a toxic nodule
Correct Answer: C — Anti-thyroid peroxidase (TPO) antibodies confirm the
autoimmune etiology of Hashimoto's thyroiditis, which is the most common cause
of hypothyroidism in iodine-sufficient areas. Levothyroxine therapy is initiated
after confirmation. Thyroid ultrasound is not routinely indicated unless nodules
are palpable or TSH remains elevated despite treatment. A thyroid scan is used to
evaluate hyperthyroidism, not hypothyroidism.
Question 2
Which of the following BEST defines diagnostic reasoning in the context of
primary care practice?
A. The process of memorizing disease presentations to quickly identify conditions
B. A type of critical thinking that involves questioning one's thinking to determine
if all possible avenues have been explored and conclusions are evidence-based
C. The systematic application of clinical guidelines without deviation for every
,patient
D. The ability to order the correct diagnostic tests based on chief complaint alone
Correct Answer: B — Diagnostic reasoning is a form of reflective critical
thinking where the clinician questions their own thought process to ensure all
possibilities have been considered and conclusions are supported by evidence. It
is not simply memorization or algorithmic application of guidelines, nor is it solely
based on test ordering.
Question 3
A 68-year-old male with a history of hypertension and type 2 diabetes presents
for a routine follow-up. His blood pressure today is 148/92 mmHg. He reports
adherence to his lisinopril 20 mg daily. Which of the following represents the
MOST appropriate next step in his management?
A. Increase lisinopril to 40 mg daily and recheck in 4 weeks
B. Add hydrochlorothiazide 12.5 mg daily
C. Order a basic metabolic panel and urinalysis before making changes
D. Recheck blood pressure at the end of the visit after 5 minutes of rest
Correct Answer: C — Before adjusting antihypertensive therapy, it is essential
to assess kidney function (BUN/creatinine) and electrolytes, particularly
potassium, as ACE inhibitors can cause hyperkalemia and renal impairment.
Urinalysis can assess for proteinuria, a marker of end-organ damage. Rushing to
increase medication or add a new agent without baseline laboratory assessment
is not evidence-based.
Question 4
A 35-year-old woman presents with a 3-day history of sore throat, fever, and
malaise. On examination, she has erythematous tonsils with exudate, tender
anterior cervical lymphadenopathy, and a temperature of 101.2°F. She has no
cough. Which of the following diagnostic approaches is MOST appropriate?
A. Prescribe amoxicillin empirically without testing
B. Perform a rapid antigen detection test (RADT) and send a throat culture if
,negative
C. Send a throat culture only
D. Obtain a complete blood count to assess for lymphocytosis
Correct Answer: B — The Centor criteria (fever, tonsillar exudate, tender
anterior cervical lymphadenopathy, absence of cough) suggest possible group A
streptococcal pharyngitis. A rapid antigen detection test should be performed,
and if negative, a throat culture should be sent in adults to confirm. Empirical
antibiotics are not recommended without testing due to the risk of unnecessary
antibiotic use and antibiotic resistance. A CBC is not specific for streptococcal
infection.
Question 5
A 45-year-old male presents with right upper quadrant abdominal pain that
radiates to his right shoulder, worse after eating fatty meals. He also reports
nausea and occasional vomiting. On examination, Murphy's sign is positive. What
is the MOST likely diagnosis?
A. Peptic ulcer disease
B. Acute pancreatitis
C. Cholecystitis
D. Gastroesophageal reflux disease
Correct Answer: C — The classic presentation of acute cholecystitis includes
right upper quadrant pain that may radiate to the right shoulder (referred pain via
the phrenic nerve), exacerbated by fatty meals, with a positive Murphy's sign
(inspiratory arrest during palpation of the right upper quadrant). Peptic ulcer
disease typically presents with epigastric pain. Acute pancreatitis presents with
severe epigastric pain radiating to the back. GERD presents with substernal
burning.
Question 6
Which of the following components is included in the History of Present Illness
(HPI) ?
, A. Past medical history and surgical history
B. Family history of chronic diseases
C. Detailed breakdown of the chief complaint using OLDCARTS
D. Social history including tobacco and alcohol use
Correct Answer: C — The HPI is specifically related to the chief complaint and
includes a detailed breakdown using the OLDCARTS mnemonic (Onset, Location,
Duration, Character, Aggravating factors, Relieving factors, Timing, Severity). Past
medical history, family history, and social history are documented separately in
the history of the present illness section of the comprehensive history.
Question 7
A 28-year-old female presents with a 2-week history of intermittent, crampy
abdominal pain, bloating, and alternating constipation and diarrhea. She denies
weight loss, blood in stool, or nocturnal symptoms. Physical examination is
unremarkable. Basic laboratory studies, including CBC, CMP, and TSH, are normal.
Stool studies are negative for ova and parasites. What is the MOST likely
diagnosis?
A. Inflammatory bowel disease
B. Celiac disease
C. Irritable bowel syndrome (IBS)
D. Chronic pancreatitis
Correct Answer: C — IBS is a functional gastrointestinal disorder
characterized by recurrent abdominal pain at least 1 day per week in the last 3
months, associated with two or more of the following: related to defecation,
associated with a change in stool frequency, or associated with a change in stool
form. The absence of "red flag" symptoms (weight loss, hematochezia, nocturnal
symptoms) and normal laboratory studies supports this diagnosis. Inflammatory
bowel disease and celiac disease typically present with more systemic symptoms
and abnormal laboratory findings.
Practicum Final – Chamberlain University
SECTION 1: FOUNDATIONS OF DIAGNOSTIC REASONING
Questions 1–10
Question 1
A 52-year-old female presents with complaints of fatigue, weight gain, and cold
intolerance over the past 4 months. On physical examination, you note dry skin,
bradycardia, and a non-tender goiter. Initial laboratory testing reveals an elevated
TSH and low free T4. Which of the following represents the BEST next step in
diagnostic reasoning?
A. Order a thyroid ultrasound to evaluate for nodules
B. Begin empiric levothyroxine therapy and recheck TSH in 6 weeks
C. Order anti-thyroid peroxidase antibodies to confirm the diagnosis
D. Order a thyroid scan to assess for a toxic nodule
Correct Answer: C — Anti-thyroid peroxidase (TPO) antibodies confirm the
autoimmune etiology of Hashimoto's thyroiditis, which is the most common cause
of hypothyroidism in iodine-sufficient areas. Levothyroxine therapy is initiated
after confirmation. Thyroid ultrasound is not routinely indicated unless nodules
are palpable or TSH remains elevated despite treatment. A thyroid scan is used to
evaluate hyperthyroidism, not hypothyroidism.
Question 2
Which of the following BEST defines diagnostic reasoning in the context of
primary care practice?
A. The process of memorizing disease presentations to quickly identify conditions
B. A type of critical thinking that involves questioning one's thinking to determine
if all possible avenues have been explored and conclusions are evidence-based
C. The systematic application of clinical guidelines without deviation for every
,patient
D. The ability to order the correct diagnostic tests based on chief complaint alone
Correct Answer: B — Diagnostic reasoning is a form of reflective critical
thinking where the clinician questions their own thought process to ensure all
possibilities have been considered and conclusions are supported by evidence. It
is not simply memorization or algorithmic application of guidelines, nor is it solely
based on test ordering.
Question 3
A 68-year-old male with a history of hypertension and type 2 diabetes presents
for a routine follow-up. His blood pressure today is 148/92 mmHg. He reports
adherence to his lisinopril 20 mg daily. Which of the following represents the
MOST appropriate next step in his management?
A. Increase lisinopril to 40 mg daily and recheck in 4 weeks
B. Add hydrochlorothiazide 12.5 mg daily
C. Order a basic metabolic panel and urinalysis before making changes
D. Recheck blood pressure at the end of the visit after 5 minutes of rest
Correct Answer: C — Before adjusting antihypertensive therapy, it is essential
to assess kidney function (BUN/creatinine) and electrolytes, particularly
potassium, as ACE inhibitors can cause hyperkalemia and renal impairment.
Urinalysis can assess for proteinuria, a marker of end-organ damage. Rushing to
increase medication or add a new agent without baseline laboratory assessment
is not evidence-based.
Question 4
A 35-year-old woman presents with a 3-day history of sore throat, fever, and
malaise. On examination, she has erythematous tonsils with exudate, tender
anterior cervical lymphadenopathy, and a temperature of 101.2°F. She has no
cough. Which of the following diagnostic approaches is MOST appropriate?
A. Prescribe amoxicillin empirically without testing
B. Perform a rapid antigen detection test (RADT) and send a throat culture if
,negative
C. Send a throat culture only
D. Obtain a complete blood count to assess for lymphocytosis
Correct Answer: B — The Centor criteria (fever, tonsillar exudate, tender
anterior cervical lymphadenopathy, absence of cough) suggest possible group A
streptococcal pharyngitis. A rapid antigen detection test should be performed,
and if negative, a throat culture should be sent in adults to confirm. Empirical
antibiotics are not recommended without testing due to the risk of unnecessary
antibiotic use and antibiotic resistance. A CBC is not specific for streptococcal
infection.
Question 5
A 45-year-old male presents with right upper quadrant abdominal pain that
radiates to his right shoulder, worse after eating fatty meals. He also reports
nausea and occasional vomiting. On examination, Murphy's sign is positive. What
is the MOST likely diagnosis?
A. Peptic ulcer disease
B. Acute pancreatitis
C. Cholecystitis
D. Gastroesophageal reflux disease
Correct Answer: C — The classic presentation of acute cholecystitis includes
right upper quadrant pain that may radiate to the right shoulder (referred pain via
the phrenic nerve), exacerbated by fatty meals, with a positive Murphy's sign
(inspiratory arrest during palpation of the right upper quadrant). Peptic ulcer
disease typically presents with epigastric pain. Acute pancreatitis presents with
severe epigastric pain radiating to the back. GERD presents with substernal
burning.
Question 6
Which of the following components is included in the History of Present Illness
(HPI) ?
, A. Past medical history and surgical history
B. Family history of chronic diseases
C. Detailed breakdown of the chief complaint using OLDCARTS
D. Social history including tobacco and alcohol use
Correct Answer: C — The HPI is specifically related to the chief complaint and
includes a detailed breakdown using the OLDCARTS mnemonic (Onset, Location,
Duration, Character, Aggravating factors, Relieving factors, Timing, Severity). Past
medical history, family history, and social history are documented separately in
the history of the present illness section of the comprehensive history.
Question 7
A 28-year-old female presents with a 2-week history of intermittent, crampy
abdominal pain, bloating, and alternating constipation and diarrhea. She denies
weight loss, blood in stool, or nocturnal symptoms. Physical examination is
unremarkable. Basic laboratory studies, including CBC, CMP, and TSH, are normal.
Stool studies are negative for ova and parasites. What is the MOST likely
diagnosis?
A. Inflammatory bowel disease
B. Celiac disease
C. Irritable bowel syndrome (IBS)
D. Chronic pancreatitis
Correct Answer: C — IBS is a functional gastrointestinal disorder
characterized by recurrent abdominal pain at least 1 day per week in the last 3
months, associated with two or more of the following: related to defecation,
associated with a change in stool frequency, or associated with a change in stool
form. The absence of "red flag" symptoms (weight loss, hematochezia, nocturnal
symptoms) and normal laboratory studies supports this diagnosis. Inflammatory
bowel disease and celiac disease typically present with more systemic symptoms
and abnormal laboratory findings.
