NR 576 DIFFERENTIAL DIAGNOSIS ADULT-GERONTOLOGY
PRIMARY CARE FINAL EXAM 2026/2027 | Questions and
Answers | Grade A 100% Correct | Pass Guaranteed
Domain 1: Clinical Reasoning & Diagnostic Process (15 Questions)
Q1: A 68-year-old male presents with progressive dyspnea on exertion, orthopnea, and
bilateral lower extremity edema over 3 weeks. Physical examination reveals elevated
JVP at 8 cm H₂O, S3 gallop, hepatomegaly, and 2+ pitting edema. ECG shows sinus
rhythm with left bundle branch block. BNP is 650 pg/mL. Which diagnostic approach is
most appropriate to differentiate between systolic and diastolic heart failure?
A. Order cardiac catheterization to measure pulmonary capillary wedge pressure
B. Perform transthoracic echocardiogram to assess left ventricular ejection fraction and
diastolic function [CORRECT]
C. Schedule cardiac MRI to evaluate myocardial tissue characterization
D. Obtain nuclear stress test to assess for coronary artery disease
Correct Answer: B
Rationale: The clinical presentation is classic for acute decompensated heart failure.
The most appropriate initial diagnostic test to differentiate systolic from diastolic heart
failure is transthoracic echocardiogram (TTE). TTE provides comprehensive
assessment of left ventricular ejection fraction (LVEF), which distinguishes HFrEF
(≤40%) from HFpEF (≥50%), and evaluates diastolic function through Doppler
,measurements of mitral inflow, tissue Doppler imaging of mitral annular velocities, and
left atrial volume. The 2022 AHA/ACC/HFSA Heart Failure Guidelines recommend
echocardiography as the cornerstone diagnostic test for all patients with suspected
heart failure.
Distractor Analysis:
● A (Cardiac catheterization): While invasive hemodynamic monitoring can confirm
elevated filling pressures, it is not the first-line test for differentiating systolic vs.
diastolic dysfunction and carries procedural risks.
● C (Cardiac MRI): Excellent for tissue characterization and etiology determination
but is not the initial test for heart failure type classification and is more expensive
with limited availability.
● D (Nuclear stress test): Evaluates for ischemic etiology but does not directly
assess systolic or diastolic function and should be performed after
echocardiography if ischemia is suspected.
Q2: A 72-year-old female with type 2 diabetes presents with fatigue, anorexia, and vague
abdominal discomfort. Laboratory studies reveal: Hemoglobin 9.2 g/dL, MCV 78 fL,
ferritin 45 ng/mL, TIBC 380 μg/dL, transferrin saturation 12%. Stool guaiac is negative.
Which condition best explains these findings?
A. Anemia of chronic disease with functional iron deficiency
B. Iron deficiency anemia secondary to occult gastrointestinal bleeding [CORRECT]
C. Sideroblastic anemia from diabetic complications
D. Thalassemia trait with coincidental diabetes
Correct Answer: B
,Rationale: This patient presents with microcytic hypochromic anemia (MCV <80 fL) with
low transferrin saturation (normal >20%) and low-normal ferritin. In the context of
diabetes, particularly in older adults, iron deficiency anemia often results from occult
gastrointestinal bleeding due to diabetic gastroparesis, angiodysplasia, or increased
risk of gastrointestinal malignancy. The negative stool guaiac does not exclude
intermittent or slow bleeding. The ferritin level of 45 ng/mL, while within "normal" range,
is insufficient for anemic patients where ferritin <100 ng/mL suggests iron deficiency in
the presence of anemia. The elevated TIBC further supports true iron deficiency rather
than anemia of chronic disease (which typically shows low TIBC).
Distractor Analysis:
● A (Anemia of chronic disease): Would present with elevated ferritin, low TIBC,
and normal/high transferrin saturation. The low transferrin saturation and
elevated TIBC argue against this diagnosis.
● C (Sideroblastic anemia): Characterized by ringed sideroblasts in bone marrow,
typically shows high iron indices with elevated ferritin, not the iron-deficient
pattern seen here.
● D (Thalassemia trait): Would show microcytosis with normal or elevated RBC
count, normal iron studies, and often a family history. The abnormal iron studies
rule this out.
Q3: A 58-year-old male smoker presents with sudden onset right-sided weakness and
aphasia. NIHSS score is 14. CT head shows no hemorrhage. Time from symptom onset
is 2.5 hours. Blood pressure is 175/95 mmHg. Which is the most appropriate immediate
management?
A. Administer IV tissue plasminogen activator (tPA) after lowering blood pressure to
<185/110 mmHg [CORRECT]
, B. Proceed directly to mechanical thrombectomy without pharmacologic intervention
C. Administer aspirin 325 mg immediately and observe
D. Obtain MRI with diffusion-weighted imaging before any intervention
Correct Answer: A
Rationale: This patient presents with acute ischemic stroke (NIHSS 14, CT negative for
hemorrhage, within 4.5-hour window) and is a candidate for IV thrombolysis with
alteplase. Current AHA/ASA guidelines recommend IV tPA for eligible patients within 3
hours (or 4.5 hours for selected patients) of symptom onset. Blood pressure must be
reduced to <185/110 mmHg before and maintained <180/105 mmHg during and after
tPA administration. The patient meets criteria: measurable deficit, CT excludes
hemorrhage, age >18, and within therapeutic window. Blood pressure management with
labetalol or nicardipine should precede tPA administration.
Distractor Analysis:
● B (Mechanical thrombectomy): Reserved for large vessel occlusion (LVO)
confirmed by vascular imaging, typically as adjunct to tPA or if tPA
contraindicated. Not first-line without imaging confirmation of LVO.
● C (Aspirin): Contraindicated within 24 hours of tPA administration due to bleeding
risk. Would delay definitive reperfusion therapy.
● D (MRI): Unnecessary delay in a clear ischemic stroke within tPA window.
Non-contrast CT is sufficient to exclude hemorrhage; time is brain.
Q4: A 45-year-old female presents with recurrent episodes of palpitations, sweating,
tremors, and confusion, occurring primarily in the early morning. Symptoms resolve with
PRIMARY CARE FINAL EXAM 2026/2027 | Questions and
Answers | Grade A 100% Correct | Pass Guaranteed
Domain 1: Clinical Reasoning & Diagnostic Process (15 Questions)
Q1: A 68-year-old male presents with progressive dyspnea on exertion, orthopnea, and
bilateral lower extremity edema over 3 weeks. Physical examination reveals elevated
JVP at 8 cm H₂O, S3 gallop, hepatomegaly, and 2+ pitting edema. ECG shows sinus
rhythm with left bundle branch block. BNP is 650 pg/mL. Which diagnostic approach is
most appropriate to differentiate between systolic and diastolic heart failure?
A. Order cardiac catheterization to measure pulmonary capillary wedge pressure
B. Perform transthoracic echocardiogram to assess left ventricular ejection fraction and
diastolic function [CORRECT]
C. Schedule cardiac MRI to evaluate myocardial tissue characterization
D. Obtain nuclear stress test to assess for coronary artery disease
Correct Answer: B
Rationale: The clinical presentation is classic for acute decompensated heart failure.
The most appropriate initial diagnostic test to differentiate systolic from diastolic heart
failure is transthoracic echocardiogram (TTE). TTE provides comprehensive
assessment of left ventricular ejection fraction (LVEF), which distinguishes HFrEF
(≤40%) from HFpEF (≥50%), and evaluates diastolic function through Doppler
,measurements of mitral inflow, tissue Doppler imaging of mitral annular velocities, and
left atrial volume. The 2022 AHA/ACC/HFSA Heart Failure Guidelines recommend
echocardiography as the cornerstone diagnostic test for all patients with suspected
heart failure.
Distractor Analysis:
● A (Cardiac catheterization): While invasive hemodynamic monitoring can confirm
elevated filling pressures, it is not the first-line test for differentiating systolic vs.
diastolic dysfunction and carries procedural risks.
● C (Cardiac MRI): Excellent for tissue characterization and etiology determination
but is not the initial test for heart failure type classification and is more expensive
with limited availability.
● D (Nuclear stress test): Evaluates for ischemic etiology but does not directly
assess systolic or diastolic function and should be performed after
echocardiography if ischemia is suspected.
Q2: A 72-year-old female with type 2 diabetes presents with fatigue, anorexia, and vague
abdominal discomfort. Laboratory studies reveal: Hemoglobin 9.2 g/dL, MCV 78 fL,
ferritin 45 ng/mL, TIBC 380 μg/dL, transferrin saturation 12%. Stool guaiac is negative.
Which condition best explains these findings?
A. Anemia of chronic disease with functional iron deficiency
B. Iron deficiency anemia secondary to occult gastrointestinal bleeding [CORRECT]
C. Sideroblastic anemia from diabetic complications
D. Thalassemia trait with coincidental diabetes
Correct Answer: B
,Rationale: This patient presents with microcytic hypochromic anemia (MCV <80 fL) with
low transferrin saturation (normal >20%) and low-normal ferritin. In the context of
diabetes, particularly in older adults, iron deficiency anemia often results from occult
gastrointestinal bleeding due to diabetic gastroparesis, angiodysplasia, or increased
risk of gastrointestinal malignancy. The negative stool guaiac does not exclude
intermittent or slow bleeding. The ferritin level of 45 ng/mL, while within "normal" range,
is insufficient for anemic patients where ferritin <100 ng/mL suggests iron deficiency in
the presence of anemia. The elevated TIBC further supports true iron deficiency rather
than anemia of chronic disease (which typically shows low TIBC).
Distractor Analysis:
● A (Anemia of chronic disease): Would present with elevated ferritin, low TIBC,
and normal/high transferrin saturation. The low transferrin saturation and
elevated TIBC argue against this diagnosis.
● C (Sideroblastic anemia): Characterized by ringed sideroblasts in bone marrow,
typically shows high iron indices with elevated ferritin, not the iron-deficient
pattern seen here.
● D (Thalassemia trait): Would show microcytosis with normal or elevated RBC
count, normal iron studies, and often a family history. The abnormal iron studies
rule this out.
Q3: A 58-year-old male smoker presents with sudden onset right-sided weakness and
aphasia. NIHSS score is 14. CT head shows no hemorrhage. Time from symptom onset
is 2.5 hours. Blood pressure is 175/95 mmHg. Which is the most appropriate immediate
management?
A. Administer IV tissue plasminogen activator (tPA) after lowering blood pressure to
<185/110 mmHg [CORRECT]
, B. Proceed directly to mechanical thrombectomy without pharmacologic intervention
C. Administer aspirin 325 mg immediately and observe
D. Obtain MRI with diffusion-weighted imaging before any intervention
Correct Answer: A
Rationale: This patient presents with acute ischemic stroke (NIHSS 14, CT negative for
hemorrhage, within 4.5-hour window) and is a candidate for IV thrombolysis with
alteplase. Current AHA/ASA guidelines recommend IV tPA for eligible patients within 3
hours (or 4.5 hours for selected patients) of symptom onset. Blood pressure must be
reduced to <185/110 mmHg before and maintained <180/105 mmHg during and after
tPA administration. The patient meets criteria: measurable deficit, CT excludes
hemorrhage, age >18, and within therapeutic window. Blood pressure management with
labetalol or nicardipine should precede tPA administration.
Distractor Analysis:
● B (Mechanical thrombectomy): Reserved for large vessel occlusion (LVO)
confirmed by vascular imaging, typically as adjunct to tPA or if tPA
contraindicated. Not first-line without imaging confirmation of LVO.
● C (Aspirin): Contraindicated within 24 hours of tPA administration due to bleeding
risk. Would delay definitive reperfusion therapy.
● D (MRI): Unnecessary delay in a clear ischemic stroke within tPA window.
Non-contrast CT is sufficient to exclude hemorrhage; time is brain.
Q4: A 45-year-old female presents with recurrent episodes of palpitations, sweating,
tremors, and confusion, occurring primarily in the early morning. Symptoms resolve with
