Diagnostic Reasoning Final Review
Questions and Answers Rated A+
28-year-old female presents with erythematous, maculopapular rash in her axilla and
complains of intense pruritis. To aid in a diagnosis, which test could be performed?
A. Tzank Smear
B. Punch Biopsy
C. KOH preparation
D. Dermoscopy - ANSWER-C. KOH preparation
Dains, p400
52-year-old male presents with a complaint of swollen right knee following a fall today at
work. The patient reports tripping and twisting his knee as he fell. The right knee
appears swollen and the patient has trouble walking on that leg without his knee giving
way. A diagnosis of torn ACL would be supported with a positive result from which test?
A. Lachman
B. McMurray
C. Yergason
D. Finkelstein - ANSWER-A. Lachman
Dains, p310
Lachman Test. Place the knee in 15° of flexion and external rotation. Grasp the distal
femur on the lateral side with one hand and the proximal tibia on the medial side with
the other. With the thumb of the tibial hand on the joint line, simultaneously pull the tibia
forward and the femur back. Estimate the degree of forward excursion. Significant
forward excursion is a positive test for an ACL tear. Bates, p690
A 13-year-old female patient presents with a history of a red patch on her trunk that was
followed several days later by many faint, erythematous patches on her trunk and arms.
They are mildly pruritic. Upon examination, the nurse practitioner notices many faint
erythematous populosquamous patches. There are no lesions on the face, palms of
hands, or soles of feet. The nurse practitioner suspects:
A) secondary syphilis
B) contact dermatitis
C) a drug reaction
D) pityriasis rosacea - ANSWER-D) pityriasis rosacea
Pityriasis rosacea eruptions begin with a Herald Patch that is followed a few days to a
few weeks later by multiple oval erythematous lesions with an inner circle of fine scales.
The lesions are usually on the trunk and extremities and line up along the skin cleavage
lines. It is most common in fall or spring and is thought to be viral in nature. If the history
,warrants and the patient has this rash present on the palms or soles of the feet, check
for secondary syphilis. Dains p362, 363, 368
A 15-year-old boy is seen in the clinic for complaints of "dull pain and pulling" in the
scrotal area. On examination, the nurse practitioner palpates a soft, irregular mass
posterior to and above the testis on the left. This mass collapses when the patient is
supine and refills when he is upright. This description is consistent with:
A) epididymitis
B) spermatocele
C) testicular torsion
D) varicocele - ANSWER-D) varicocele
A varicocele consists of dilated, tortuous varicose veins in the spermatic cord caused by
incompetent valves within the vein. Symptoms include dull pain or a constant pulling or
dragging feeling, or the individual may be asymptomatic. When palpating the mass, the
examiner will feel a soft, irregular mass posterior to and above the testis that collapses
when the individual is supine and refills when the individual is upright.
A 17-year-old high school senior presents to your clinic in acute respiratory distress.
Between shallow breaths he states he was at home finishing his homework when he
suddenly began having right-sided chest pain and severe shortness of breath. He
denies any recent traumas or illnesses. His past medical history is unremarkable. He
doesn't smoke but drinks several beers on the weekend. He has tried marijuana several
times but denies any other illegal drugs. He is an honors student and is on the
basketball team. His parents are both in good health. He denies any recent weight gain,
weight loss, fever, or night sweats. On examination you see a tall, thin young man in
obvious distress. He is diaphoretic and is breathing at a rate of 35 breaths per minute.
On auscultation you hear no breath sounds on the right side of his superior chest wall.
On percussion he is hyperresonant over the right upper lobe. With palpation he h -
ANSWER-A) Spontaneous pneumothorax
Spontaneous pneumothorax occurs suddenly, causing severe dyspnea and chest pain
on the affected side. It is more common in thin young males. On auscultation of the
affected side there will be no breath sounds and on percussion there is hyperresonance
or tympany. There will be an absence of fremitus to palpation. Given this young man's
habitus and pneumothorax, you may consider looking for features of Marfan's
syndrome.
A 2-year-old child comes to the clinic for a persistent cough for past 2 days that started
abruptly. In the room is the mother and 4-year-old twin siblings of the patient, the
mother appears to be flustered as the siblings are rambunctious and occupy much of
her attention. Examination reveals a normal O2 saturation, a nonproductive cough with
normal findings in ear, nose, and throat. Wheezing is noted in the auscultation of breath
sounds. The most pertinent question that you can ask at this time :
A. What was she doing just before the cough started?
B. Was she born at term?
, C. Have you noticed a rash?
D. Have you noticed any new teeth coming in? - ANSWER-A. What was she doing just
before the cough started?
(rule in/out foreign object aspiration)
A 21-year-old college senior presents to your clinic, complaining of shortness of breath
and a nonproductive nocturnal cough. She states she used to feel this way only with
extreme exercise, but lately she has felt this way continuously. She denies any other
upper respiratory symptoms, chest pain, gastrointestinal symptoms, or urinary tract
symptoms. Her past medical history is significant only for seasonal allergies, for which
she takes a nasal steroid spray but is otherwise on no other medications. She has had
no surgeries. Her mother has allergies and eczema and her father has high blood
pressure. She is an only child. She denies smoking and illegal drug use but drinks three
to four alcoholic beverages per weekend. She is a junior in finance at a local university
and she has recently started a job as a bartender in town. On examination she is in no
acute distress and her temperature is 98.6. Her blood pressure is - ANSWER-C)
Asthma
Asthma causes shortness of breath and a nocturnal cough. It is often associated with a
history of allergies and can be made worse by exercise or irritants such as smoke in a
bar. On auscultation there can be normal to decreased air movement. Wheezing is
heard on expiration and sometimes inspiration. The duration of wheezing in expiration
usually correlates with severity of illness, so it is important to document this length (e.g.,
wheezes heard halfway through exhalation). Realize that in severe asthma, wheezes
may not be heard because of the lack of air movement. Paradoxically, these patients
may have more wheezes after treatment, which actually indicates an improvement in
condition. Peak flow measurements help to discern this.
A 24-year-old female patient with normal vital signs presents with lesions on her lip that
erupted after she endured a tingling and burning sensation in the same area. All other
areas of her skin are normal. She says no one else in her family has this symptom. The
patient is very worried about them clearing up before her wedding in two weeks. The
lesions appear as vesicles surrounded by an erythematous base. Your top differential
diagnosis is most likely:
A) herpes zoster virus
B) impetigo
C) herpes simplex virus
D) hand foot mouth disease - ANSWER-C) herpes simplex virus
Dains 369, 373
A 25-year-old accountant presents to your clinic, complaining of intermittent lower right-
sided chest pain for several days. He describes it as knifelike and states it only lasts for
3 to 5 seconds, taking his breath away. He states he feels like he has to breathe
shallowly to keep it from recurring. The only thing that makes it better is lying quietly on
his right side. It is much worse when he takes a deep breath. He has taken some
Questions and Answers Rated A+
28-year-old female presents with erythematous, maculopapular rash in her axilla and
complains of intense pruritis. To aid in a diagnosis, which test could be performed?
A. Tzank Smear
B. Punch Biopsy
C. KOH preparation
D. Dermoscopy - ANSWER-C. KOH preparation
Dains, p400
52-year-old male presents with a complaint of swollen right knee following a fall today at
work. The patient reports tripping and twisting his knee as he fell. The right knee
appears swollen and the patient has trouble walking on that leg without his knee giving
way. A diagnosis of torn ACL would be supported with a positive result from which test?
A. Lachman
B. McMurray
C. Yergason
D. Finkelstein - ANSWER-A. Lachman
Dains, p310
Lachman Test. Place the knee in 15° of flexion and external rotation. Grasp the distal
femur on the lateral side with one hand and the proximal tibia on the medial side with
the other. With the thumb of the tibial hand on the joint line, simultaneously pull the tibia
forward and the femur back. Estimate the degree of forward excursion. Significant
forward excursion is a positive test for an ACL tear. Bates, p690
A 13-year-old female patient presents with a history of a red patch on her trunk that was
followed several days later by many faint, erythematous patches on her trunk and arms.
They are mildly pruritic. Upon examination, the nurse practitioner notices many faint
erythematous populosquamous patches. There are no lesions on the face, palms of
hands, or soles of feet. The nurse practitioner suspects:
A) secondary syphilis
B) contact dermatitis
C) a drug reaction
D) pityriasis rosacea - ANSWER-D) pityriasis rosacea
Pityriasis rosacea eruptions begin with a Herald Patch that is followed a few days to a
few weeks later by multiple oval erythematous lesions with an inner circle of fine scales.
The lesions are usually on the trunk and extremities and line up along the skin cleavage
lines. It is most common in fall or spring and is thought to be viral in nature. If the history
,warrants and the patient has this rash present on the palms or soles of the feet, check
for secondary syphilis. Dains p362, 363, 368
A 15-year-old boy is seen in the clinic for complaints of "dull pain and pulling" in the
scrotal area. On examination, the nurse practitioner palpates a soft, irregular mass
posterior to and above the testis on the left. This mass collapses when the patient is
supine and refills when he is upright. This description is consistent with:
A) epididymitis
B) spermatocele
C) testicular torsion
D) varicocele - ANSWER-D) varicocele
A varicocele consists of dilated, tortuous varicose veins in the spermatic cord caused by
incompetent valves within the vein. Symptoms include dull pain or a constant pulling or
dragging feeling, or the individual may be asymptomatic. When palpating the mass, the
examiner will feel a soft, irregular mass posterior to and above the testis that collapses
when the individual is supine and refills when the individual is upright.
A 17-year-old high school senior presents to your clinic in acute respiratory distress.
Between shallow breaths he states he was at home finishing his homework when he
suddenly began having right-sided chest pain and severe shortness of breath. He
denies any recent traumas or illnesses. His past medical history is unremarkable. He
doesn't smoke but drinks several beers on the weekend. He has tried marijuana several
times but denies any other illegal drugs. He is an honors student and is on the
basketball team. His parents are both in good health. He denies any recent weight gain,
weight loss, fever, or night sweats. On examination you see a tall, thin young man in
obvious distress. He is diaphoretic and is breathing at a rate of 35 breaths per minute.
On auscultation you hear no breath sounds on the right side of his superior chest wall.
On percussion he is hyperresonant over the right upper lobe. With palpation he h -
ANSWER-A) Spontaneous pneumothorax
Spontaneous pneumothorax occurs suddenly, causing severe dyspnea and chest pain
on the affected side. It is more common in thin young males. On auscultation of the
affected side there will be no breath sounds and on percussion there is hyperresonance
or tympany. There will be an absence of fremitus to palpation. Given this young man's
habitus and pneumothorax, you may consider looking for features of Marfan's
syndrome.
A 2-year-old child comes to the clinic for a persistent cough for past 2 days that started
abruptly. In the room is the mother and 4-year-old twin siblings of the patient, the
mother appears to be flustered as the siblings are rambunctious and occupy much of
her attention. Examination reveals a normal O2 saturation, a nonproductive cough with
normal findings in ear, nose, and throat. Wheezing is noted in the auscultation of breath
sounds. The most pertinent question that you can ask at this time :
A. What was she doing just before the cough started?
B. Was she born at term?
, C. Have you noticed a rash?
D. Have you noticed any new teeth coming in? - ANSWER-A. What was she doing just
before the cough started?
(rule in/out foreign object aspiration)
A 21-year-old college senior presents to your clinic, complaining of shortness of breath
and a nonproductive nocturnal cough. She states she used to feel this way only with
extreme exercise, but lately she has felt this way continuously. She denies any other
upper respiratory symptoms, chest pain, gastrointestinal symptoms, or urinary tract
symptoms. Her past medical history is significant only for seasonal allergies, for which
she takes a nasal steroid spray but is otherwise on no other medications. She has had
no surgeries. Her mother has allergies and eczema and her father has high blood
pressure. She is an only child. She denies smoking and illegal drug use but drinks three
to four alcoholic beverages per weekend. She is a junior in finance at a local university
and she has recently started a job as a bartender in town. On examination she is in no
acute distress and her temperature is 98.6. Her blood pressure is - ANSWER-C)
Asthma
Asthma causes shortness of breath and a nocturnal cough. It is often associated with a
history of allergies and can be made worse by exercise or irritants such as smoke in a
bar. On auscultation there can be normal to decreased air movement. Wheezing is
heard on expiration and sometimes inspiration. The duration of wheezing in expiration
usually correlates with severity of illness, so it is important to document this length (e.g.,
wheezes heard halfway through exhalation). Realize that in severe asthma, wheezes
may not be heard because of the lack of air movement. Paradoxically, these patients
may have more wheezes after treatment, which actually indicates an improvement in
condition. Peak flow measurements help to discern this.
A 24-year-old female patient with normal vital signs presents with lesions on her lip that
erupted after she endured a tingling and burning sensation in the same area. All other
areas of her skin are normal. She says no one else in her family has this symptom. The
patient is very worried about them clearing up before her wedding in two weeks. The
lesions appear as vesicles surrounded by an erythematous base. Your top differential
diagnosis is most likely:
A) herpes zoster virus
B) impetigo
C) herpes simplex virus
D) hand foot mouth disease - ANSWER-C) herpes simplex virus
Dains 369, 373
A 25-year-old accountant presents to your clinic, complaining of intermittent lower right-
sided chest pain for several days. He describes it as knifelike and states it only lasts for
3 to 5 seconds, taking his breath away. He states he feels like he has to breathe
shallowly to keep it from recurring. The only thing that makes it better is lying quietly on
his right side. It is much worse when he takes a deep breath. He has taken some
