NR-511 Advanced Clinical Reasoning:
Complex Presentations, Diagnostic
Challenges, & Evidence-Based
Management in Primary Care
Questions 1–150
1. A 34-year-old female presents with episodic dizziness, palpitations, and presyncope. She has
a history of anxiety. ECG shows a heart rate of 110 bpm with subtle ST elevations in V1-V3.
Which medication should be avoided?
A) Beta-blockers
B) Sodium channel blockers (e.g., flecainide)
C) Calcium channel blockers
D) Benzodiazepines
Correct Answer: B
Rationale: ECG pattern suggests Brugada syndrome; sodium channel blockers can induce
malignant arrhythmias.
2. A 72-year-old male with a 3-day history of right-sided headache, scalp tenderness, and jaw
pain while chewing. ESR 115 mm/hr. What is the most appropriate initial management?
A) Temporal artery biopsy within 48 hours
B) High-dose prednisone 60 mg daily and arrange biopsy
C) MRI of the head
D) Observation with aspirin
Correct Answer: B
Rationale: Giant cell arteritis; steroids should not wait for biopsy to prevent vision loss.
3. A 55-year-old female presents with progressive dyspnea on exertion and a dry cough. HRCT
shows bilateral reticular opacities with honeycombing in the basilar regions. What is the most
likely diagnosis?
,A) Sarcoidosis
B) Hypersensitivity pneumonitis
C) Idiopathic pulmonary fibrosis (IPF)
D) Cryptogenic organizing pneumonia
Correct Answer: C
Rationale: Basilar predominant honeycombing and reticular changes are classic for usual
interstitial pneumonia (UIP) pattern in IPF.
4. A 28-year-old male presents with acute-onset testicular pain, nausea, and vomiting. The
testis is tender, horizontal lie, and the cremasteric reflex is absent. What is the next best step?
A) Scrotal ultrasound with Doppler
B) Emergent surgical exploration
C) Empirical antibiotics for epididymitis
D) Urinalysis and urine culture
Correct Answer: B
Rationale: High suspicion for testicular torsion; surgery should not be delayed for imaging.
5. Which of the following is a first-line agent for neuropathic pain in a patient with chronic
kidney disease (eGFR 35 mL/min)?
A) Gabapentin
B) Pregabalin
C) Duloxetine
D) Amitriptyline
Correct Answer: C
Rationale: Duloxetine does not require renal dose adjustment; gabapentin and pregabalin
require reduction.
6. A 66-year-old female with osteoporosis is on alendronate for 5 years. She develops
atraumatic thigh pain. X-ray shows a lucent line in the lateral femoral cortex. What is the most
appropriate next step?
A) Continue alendronate and add calcium
B) Switch to denosumab
C) Stop bisphosphonate and refer to orthopedics
D) Order a bone scan
,Correct Answer: C
Rationale: Atypical femoral fracture; stop bisphosphonate and assess for incomplete
fracture.
7. A 42-year-old male with HIV (CD4 120) presents with fever, headache, and confusion. MRI
shows multiple ring-enhancing lesions. What is the most likely etiology?
A) Primary CNS lymphoma
B) Toxoplasmosis
C) Cryptococcal meningitis
D) Tuberculoma
Correct Answer: B
Rationale: Ring-enhancing lesions in advanced HIV are most commonly toxoplasmosis;
empiric treatment is indicated.
8. A 58-year-old male with a 40-pack-year smoking history presents with hemoptysis and
weight loss. CXR shows a right hilar mass. What is the next most appropriate diagnostic step?
A) CT chest with contrast
B) PET-CT scan
C) Bronchoscopy with biopsy
D) Sputum cytology x 3
Correct Answer: C
Rationale: Tissue diagnosis is needed; bronchoscopy is best for central hilar lesions.
9. A 50-year-old female with a history of GERD presents with dysphagia to solids and liquids,
regurgitation of undigested food, and chest pain. Barium swallow shows a "bird-beak"
appearance. What is the most likely diagnosis?
A) Esophageal cancer
B) Achalasia
C) Diffuse esophageal spasm
D) Eosinophilic esophagitis
Correct Answer: B
Rationale: Achalasia presents with dysphagia to both solids and liquids; bird-beak sign is
classic.
, 10. A 35-year-old obese female presents with hirsutism, oligomenorrhea, and acanthosis
nigricans. Labs: total testosterone elevated, LH:FSH ratio 2.5:1. What is the most appropriate
next step?
A) Ovarian ultrasound
B) 17-hydroxyprogesterone level
C) Dexamethasone suppression test
D) MRI of the adrenal glands
Correct Answer: A
Rationale: PCOS diagnosis requires ultrasound evidence of polycystic ovaries after excluding
other causes.
11. A 68-year-old male with atrial fibrillation on warfarin presents with sudden severe
headache, vomiting, and right-sided weakness. INR is 4.2. CT head shows left-sided
intraparenchymal hemorrhage. What is the next best step?
A) Fresh frozen plasma and vitamin K
B) Hold warfarin only
C) Platelet transfusion
D) rFVIIa
Correct Answer: A
Rationale: Life-threatening bleed requires reversal with FFP or prothrombin complex
concentrate plus vitamin K.
12. A 22-year-old female presents with fatigue, weight gain, cold intolerance, and constipation.
TSH is 45 mIU/L, free T4 is low. TPO antibodies are positive. What is the most appropriate initial
treatment?
A) Levothyroxine 1.6 mcg/kg/day
B) Levothyroxine 25 mcg daily
C) Liothyronine 25 mcg daily
D) Observation with repeat TSH in 3 months
Correct Answer: A
Rationale: Full replacement dose for young, healthy patient. Start with estimated full dose.
13. A 60-year-old male with diabetes and hypertension reports acute-onset, painless vision loss
in the right eye over seconds. Fundoscopy shows a cherry-red spot and retinal pallor. What is
the most likely diagnosis?
Complex Presentations, Diagnostic
Challenges, & Evidence-Based
Management in Primary Care
Questions 1–150
1. A 34-year-old female presents with episodic dizziness, palpitations, and presyncope. She has
a history of anxiety. ECG shows a heart rate of 110 bpm with subtle ST elevations in V1-V3.
Which medication should be avoided?
A) Beta-blockers
B) Sodium channel blockers (e.g., flecainide)
C) Calcium channel blockers
D) Benzodiazepines
Correct Answer: B
Rationale: ECG pattern suggests Brugada syndrome; sodium channel blockers can induce
malignant arrhythmias.
2. A 72-year-old male with a 3-day history of right-sided headache, scalp tenderness, and jaw
pain while chewing. ESR 115 mm/hr. What is the most appropriate initial management?
A) Temporal artery biopsy within 48 hours
B) High-dose prednisone 60 mg daily and arrange biopsy
C) MRI of the head
D) Observation with aspirin
Correct Answer: B
Rationale: Giant cell arteritis; steroids should not wait for biopsy to prevent vision loss.
3. A 55-year-old female presents with progressive dyspnea on exertion and a dry cough. HRCT
shows bilateral reticular opacities with honeycombing in the basilar regions. What is the most
likely diagnosis?
,A) Sarcoidosis
B) Hypersensitivity pneumonitis
C) Idiopathic pulmonary fibrosis (IPF)
D) Cryptogenic organizing pneumonia
Correct Answer: C
Rationale: Basilar predominant honeycombing and reticular changes are classic for usual
interstitial pneumonia (UIP) pattern in IPF.
4. A 28-year-old male presents with acute-onset testicular pain, nausea, and vomiting. The
testis is tender, horizontal lie, and the cremasteric reflex is absent. What is the next best step?
A) Scrotal ultrasound with Doppler
B) Emergent surgical exploration
C) Empirical antibiotics for epididymitis
D) Urinalysis and urine culture
Correct Answer: B
Rationale: High suspicion for testicular torsion; surgery should not be delayed for imaging.
5. Which of the following is a first-line agent for neuropathic pain in a patient with chronic
kidney disease (eGFR 35 mL/min)?
A) Gabapentin
B) Pregabalin
C) Duloxetine
D) Amitriptyline
Correct Answer: C
Rationale: Duloxetine does not require renal dose adjustment; gabapentin and pregabalin
require reduction.
6. A 66-year-old female with osteoporosis is on alendronate for 5 years. She develops
atraumatic thigh pain. X-ray shows a lucent line in the lateral femoral cortex. What is the most
appropriate next step?
A) Continue alendronate and add calcium
B) Switch to denosumab
C) Stop bisphosphonate and refer to orthopedics
D) Order a bone scan
,Correct Answer: C
Rationale: Atypical femoral fracture; stop bisphosphonate and assess for incomplete
fracture.
7. A 42-year-old male with HIV (CD4 120) presents with fever, headache, and confusion. MRI
shows multiple ring-enhancing lesions. What is the most likely etiology?
A) Primary CNS lymphoma
B) Toxoplasmosis
C) Cryptococcal meningitis
D) Tuberculoma
Correct Answer: B
Rationale: Ring-enhancing lesions in advanced HIV are most commonly toxoplasmosis;
empiric treatment is indicated.
8. A 58-year-old male with a 40-pack-year smoking history presents with hemoptysis and
weight loss. CXR shows a right hilar mass. What is the next most appropriate diagnostic step?
A) CT chest with contrast
B) PET-CT scan
C) Bronchoscopy with biopsy
D) Sputum cytology x 3
Correct Answer: C
Rationale: Tissue diagnosis is needed; bronchoscopy is best for central hilar lesions.
9. A 50-year-old female with a history of GERD presents with dysphagia to solids and liquids,
regurgitation of undigested food, and chest pain. Barium swallow shows a "bird-beak"
appearance. What is the most likely diagnosis?
A) Esophageal cancer
B) Achalasia
C) Diffuse esophageal spasm
D) Eosinophilic esophagitis
Correct Answer: B
Rationale: Achalasia presents with dysphagia to both solids and liquids; bird-beak sign is
classic.
, 10. A 35-year-old obese female presents with hirsutism, oligomenorrhea, and acanthosis
nigricans. Labs: total testosterone elevated, LH:FSH ratio 2.5:1. What is the most appropriate
next step?
A) Ovarian ultrasound
B) 17-hydroxyprogesterone level
C) Dexamethasone suppression test
D) MRI of the adrenal glands
Correct Answer: A
Rationale: PCOS diagnosis requires ultrasound evidence of polycystic ovaries after excluding
other causes.
11. A 68-year-old male with atrial fibrillation on warfarin presents with sudden severe
headache, vomiting, and right-sided weakness. INR is 4.2. CT head shows left-sided
intraparenchymal hemorrhage. What is the next best step?
A) Fresh frozen plasma and vitamin K
B) Hold warfarin only
C) Platelet transfusion
D) rFVIIa
Correct Answer: A
Rationale: Life-threatening bleed requires reversal with FFP or prothrombin complex
concentrate plus vitamin K.
12. A 22-year-old female presents with fatigue, weight gain, cold intolerance, and constipation.
TSH is 45 mIU/L, free T4 is low. TPO antibodies are positive. What is the most appropriate initial
treatment?
A) Levothyroxine 1.6 mcg/kg/day
B) Levothyroxine 25 mcg daily
C) Liothyronine 25 mcg daily
D) Observation with repeat TSH in 3 months
Correct Answer: A
Rationale: Full replacement dose for young, healthy patient. Start with estimated full dose.
13. A 60-year-old male with diabetes and hypertension reports acute-onset, painless vision loss
in the right eye over seconds. Fundoscopy shows a cherry-red spot and retinal pallor. What is
the most likely diagnosis?
