Page 1 of 104
NR 602 SLOAN GLEN CASE SOLUTION EXAM LATEST VERSION
QUESTIONS AND ANSWERS 2026 EDITION
NR 602 Sloan Glen Case Solution: 250 Multiple Choice Questions with Rationales
SECTION 1: PEDIATRIC DIFFERENTIAL DIAGNOSIS - SLIPPING GRADES
(Questions 1-50)
1. A 10-year-old patient presents with declining academic performance, snoring
reported by parents, and teacher concerns about inattention. What is the most likely
primary diagnosis that should be considered based on this presentation?
A. Attention Deficit Hyperactivity Disorder (ADHD)
B. Obstructive Sleep Apnea (OSA)
C. Hypothyroidism
D. Generalized Anxiety Disorder
Answer: B. Obstructive Sleep Apnea (OSA)
Rationale: The classic triad of snoring, daytime inattention, and declining academic
performance strongly suggests OSA as the primary differential. Studies indicate that OSA is
often the leading diagnosis when evaluating pediatric patients with slipping grades and sleep
disturbances . Sleep-disordered breathing leads to fragmented sleep, resulting in cognitive
impairment and poor school performance. While ADHD, hypothyroidism, and anxiety can
present similarly, the presence of snoring significantly elevates OSA in the differential
diagnosis. The comprehensive case study identifies OSA as the number one differential for
Avery Brook's presentation .
2. When evaluating a child with slipping grades, which historical element is considered
most critical for differentiating between ADHD and OSA as primary diagnoses?
A. Family history of learning disabilities
B. Presence of snoring and quality of sleep
C. The child's performance on standardized testing
D. The child's medication history
, Page 2 of 104
Answer: B. Presence of snoring and quality of sleep
Rationale: Sleep quality assessment, including snoring presence, is the most critical
differentiating factor between ADHD and OSA. Children with OSA often have disrupted sleep
architecture leading to daytime symptoms that mimic ADHD . In contrast, ADHD is
characterized by persistent inattention, hyperactivity, and impulsivity regardless of sleep
quality. Obtaining a detailed sleep history including snoring patterns, witnessed apneas,
restless sleep, and daytime sleepiness is essential for appropriate differential diagnosis .
3. In the comprehensive history-taking process for a child with slipping grades, which
element belongs in the pivotal concepts table for a complete pediatric assessment?
A. The child's favorite school subject
B. Onset and duration of academic decline
C. The child's preferred extracurricular activities
D. The family's annual household income
Answer: B. Onset and duration of academic decline
Rationale: The pivotal concepts table includes critical historical elements such as onset of
symptoms, school behavior, sleep quality, vision and hearing screening, attention patterns,
mood assessment, medical history, family history (including ADHD and hypothyroidism), and
social history . Onset and duration are essential for understanding whether the academic
decline is acute or chronic. Family household income, while relevant for social determinants
of health, is not a standard component of the pivotal concepts table. The comprehensive case
study emphasizes including onset, school behavior, sleep quality, attention, mood, and family
history .
4. A 10-year-old child presenting with slipping grades has a family history significant
for hypothyroidism. Which diagnostic test should the primary care provider consider as
part of the initial workup?
A. Polysomnography
B. Thyroid function testing
C. Electroencephalogram
D. Comprehensive metabolic panel
Answer: B. Thyroid function testing
Rationale: When family history includes hypothyroidism in a child with declining academic
performance, thyroid function testing is indicated to rule out this potentially reversible cause
, Page 3 of 104
of cognitive impairment. The family history section of the pivotal concepts table specifically
includes hypothyroidism as a significant consideration . Hypothyroidism can cause fatigue,
poor concentration, and cognitive slowing that manifests as slipping grades.
Polysomnography is appropriate for OSA evaluation, not hypothyroidism screening.
Comprehensive metabolic panel and EEG are not the primary screening tests for
hypothyroidism .
5. The physical examination of a child with suspected OSA should include which of the
following focused assessments?
A. Fundoscopic examination
B. Tonsillar hypertrophy assessment
C. Deep tendon reflex testing
D. Abdominal palpation
Answer: B. Tonsillar hypertrophy assessment
Rationale: Physical examination for OSA should include focused assessment of the upper
airway, particularly tonsillar size, adenoidal facies, and signs of mouth breathing. Tonsillar
hypertrophy is a common cause of pediatric OSA and can be assessed using the Brodsky
grading scale . While other examination components are part of a comprehensive evaluation,
assessing for tonsillar hypertrophy is specifically relevant to OSA diagnosis. The
comprehensive case study includes physical examination findings as a key component of the
assessment .
6. A child with OSA who undergoes polysomnography would most likely demonstrate
which finding?
A. Normal sleep architecture
B. Apnea-hypopnea index greater than 1
C. Decreased REM sleep latency
D. Increased slow-wave sleep
Answer: B. Apnea-hypopnea index greater than 1
Rationale: Polysomnography is the gold standard diagnostic test for OSA, with an apnea-
hypopnea index (AHI) greater than 1 considered diagnostic in children. Unlike adults,
children may have significant clinical symptoms even with relatively low AHI values . The
finding of an AHI greater than 1 confirms the diagnosis of OSA and helps guide treatment
, Page 4 of 104
decisions including possible surgical intervention. Normal sleep architecture and other
findings would not be expected in a child with symptomatic OSA .
7. When obtaining a social history for a 10-year-old with slipping grades, which factor is
specifically emphasized in the comprehensive case study assessment?
A. The child's favorite foods
B. The child's vaccination status
C. Parental separation or family structure changes
D. The child's pet ownership
Answer: C. Parental separation or family structure changes
Rationale: Social history assessment for the child with slipping grades includes evaluation of
family structure, parental separation, and household stressors that may contribute to
academic decline. The comprehensive case study specifically includes social history
including parental separation as a key component of the assessment . Family disruptions can
significantly impact school performance, attention, and behavior. While vaccination status
and other social factors are important, parental separation is specifically emphasized in the
social history section of the comprehensive evaluation .
8. A child presents with slipping grades, snoring, and morning headaches. The primary
care provider should suspect which condition most strongly based on this presentation?
A. Migraine headaches
B. Obstructive Sleep Apnea
C. Sinusitis
D. Tension headaches
Answer: B. Obstructive Sleep Apnea
Rationale: Morning headaches in combination with snoring and declining academic
performance are classic presenting symptoms of OSA in children. The sleep disruption and
nocturnal hypoxia associated with OSA can lead to morning headaches, daytime fatigue, and
cognitive impairment . While migraines, sinusitis, and tension headaches can cause
headaches, the combination with snoring and academic decline points strongly toward OSA.
The comprehensive case study identifies OSA as the primary differential when these
symptoms are present .
NR 602 SLOAN GLEN CASE SOLUTION EXAM LATEST VERSION
QUESTIONS AND ANSWERS 2026 EDITION
NR 602 Sloan Glen Case Solution: 250 Multiple Choice Questions with Rationales
SECTION 1: PEDIATRIC DIFFERENTIAL DIAGNOSIS - SLIPPING GRADES
(Questions 1-50)
1. A 10-year-old patient presents with declining academic performance, snoring
reported by parents, and teacher concerns about inattention. What is the most likely
primary diagnosis that should be considered based on this presentation?
A. Attention Deficit Hyperactivity Disorder (ADHD)
B. Obstructive Sleep Apnea (OSA)
C. Hypothyroidism
D. Generalized Anxiety Disorder
Answer: B. Obstructive Sleep Apnea (OSA)
Rationale: The classic triad of snoring, daytime inattention, and declining academic
performance strongly suggests OSA as the primary differential. Studies indicate that OSA is
often the leading diagnosis when evaluating pediatric patients with slipping grades and sleep
disturbances . Sleep-disordered breathing leads to fragmented sleep, resulting in cognitive
impairment and poor school performance. While ADHD, hypothyroidism, and anxiety can
present similarly, the presence of snoring significantly elevates OSA in the differential
diagnosis. The comprehensive case study identifies OSA as the number one differential for
Avery Brook's presentation .
2. When evaluating a child with slipping grades, which historical element is considered
most critical for differentiating between ADHD and OSA as primary diagnoses?
A. Family history of learning disabilities
B. Presence of snoring and quality of sleep
C. The child's performance on standardized testing
D. The child's medication history
, Page 2 of 104
Answer: B. Presence of snoring and quality of sleep
Rationale: Sleep quality assessment, including snoring presence, is the most critical
differentiating factor between ADHD and OSA. Children with OSA often have disrupted sleep
architecture leading to daytime symptoms that mimic ADHD . In contrast, ADHD is
characterized by persistent inattention, hyperactivity, and impulsivity regardless of sleep
quality. Obtaining a detailed sleep history including snoring patterns, witnessed apneas,
restless sleep, and daytime sleepiness is essential for appropriate differential diagnosis .
3. In the comprehensive history-taking process for a child with slipping grades, which
element belongs in the pivotal concepts table for a complete pediatric assessment?
A. The child's favorite school subject
B. Onset and duration of academic decline
C. The child's preferred extracurricular activities
D. The family's annual household income
Answer: B. Onset and duration of academic decline
Rationale: The pivotal concepts table includes critical historical elements such as onset of
symptoms, school behavior, sleep quality, vision and hearing screening, attention patterns,
mood assessment, medical history, family history (including ADHD and hypothyroidism), and
social history . Onset and duration are essential for understanding whether the academic
decline is acute or chronic. Family household income, while relevant for social determinants
of health, is not a standard component of the pivotal concepts table. The comprehensive case
study emphasizes including onset, school behavior, sleep quality, attention, mood, and family
history .
4. A 10-year-old child presenting with slipping grades has a family history significant
for hypothyroidism. Which diagnostic test should the primary care provider consider as
part of the initial workup?
A. Polysomnography
B. Thyroid function testing
C. Electroencephalogram
D. Comprehensive metabolic panel
Answer: B. Thyroid function testing
Rationale: When family history includes hypothyroidism in a child with declining academic
performance, thyroid function testing is indicated to rule out this potentially reversible cause
, Page 3 of 104
of cognitive impairment. The family history section of the pivotal concepts table specifically
includes hypothyroidism as a significant consideration . Hypothyroidism can cause fatigue,
poor concentration, and cognitive slowing that manifests as slipping grades.
Polysomnography is appropriate for OSA evaluation, not hypothyroidism screening.
Comprehensive metabolic panel and EEG are not the primary screening tests for
hypothyroidism .
5. The physical examination of a child with suspected OSA should include which of the
following focused assessments?
A. Fundoscopic examination
B. Tonsillar hypertrophy assessment
C. Deep tendon reflex testing
D. Abdominal palpation
Answer: B. Tonsillar hypertrophy assessment
Rationale: Physical examination for OSA should include focused assessment of the upper
airway, particularly tonsillar size, adenoidal facies, and signs of mouth breathing. Tonsillar
hypertrophy is a common cause of pediatric OSA and can be assessed using the Brodsky
grading scale . While other examination components are part of a comprehensive evaluation,
assessing for tonsillar hypertrophy is specifically relevant to OSA diagnosis. The
comprehensive case study includes physical examination findings as a key component of the
assessment .
6. A child with OSA who undergoes polysomnography would most likely demonstrate
which finding?
A. Normal sleep architecture
B. Apnea-hypopnea index greater than 1
C. Decreased REM sleep latency
D. Increased slow-wave sleep
Answer: B. Apnea-hypopnea index greater than 1
Rationale: Polysomnography is the gold standard diagnostic test for OSA, with an apnea-
hypopnea index (AHI) greater than 1 considered diagnostic in children. Unlike adults,
children may have significant clinical symptoms even with relatively low AHI values . The
finding of an AHI greater than 1 confirms the diagnosis of OSA and helps guide treatment
, Page 4 of 104
decisions including possible surgical intervention. Normal sleep architecture and other
findings would not be expected in a child with symptomatic OSA .
7. When obtaining a social history for a 10-year-old with slipping grades, which factor is
specifically emphasized in the comprehensive case study assessment?
A. The child's favorite foods
B. The child's vaccination status
C. Parental separation or family structure changes
D. The child's pet ownership
Answer: C. Parental separation or family structure changes
Rationale: Social history assessment for the child with slipping grades includes evaluation of
family structure, parental separation, and household stressors that may contribute to
academic decline. The comprehensive case study specifically includes social history
including parental separation as a key component of the assessment . Family disruptions can
significantly impact school performance, attention, and behavior. While vaccination status
and other social factors are important, parental separation is specifically emphasized in the
social history section of the comprehensive evaluation .
8. A child presents with slipping grades, snoring, and morning headaches. The primary
care provider should suspect which condition most strongly based on this presentation?
A. Migraine headaches
B. Obstructive Sleep Apnea
C. Sinusitis
D. Tension headaches
Answer: B. Obstructive Sleep Apnea
Rationale: Morning headaches in combination with snoring and declining academic
performance are classic presenting symptoms of OSA in children. The sleep disruption and
nocturnal hypoxia associated with OSA can lead to morning headaches, daytime fatigue, and
cognitive impairment . While migraines, sinusitis, and tension headaches can cause
headaches, the combination with snoring and academic decline points strongly toward OSA.
The comprehensive case study identifies OSA as the primary differential when these
symptoms are present .
