NR 511 Exam 4: Differential Diagnosis - Chamberlain
University Updated and Latest Questions and Correct
Answers with Rationale
1. A 45-year-old female presents with sharp right upper quadrant (RUQ) abdominal pain that radiates to her
right shoulder, occurring primarily after eating fried foods. Which diagnosis is most likely?
A. Acute Pancreatitis
B. Acute Cholecystitis
C. Gastroesophageal Reflux Disease (GERD)
D. Peptic Ulcer Disease
Correct Answer: B
Rationale: The clinical presentation of RUQ pain triggered by fatty meals is highly characteristic of
biliary colic or cholecystitis. Radiation to the right shoulder, known as Boas’ sign, is a common finding in
gallbladder inflammation. Acute pancreatitis usually presents with epigastric pain that radiates to the
back rather than the shoulder. GERD typically presents as retrosternal burning rather than focal RUQ
tenderness. Initial diagnostic imaging should include a right upper quadrant ultrasound to assess for
stones or wall thickening.
2. A 62-year-old male reports a 3-month history of progressive shortness of breath and a persistent dry
cough. He has a 40-pack-year smoking history and shows signs of digital clubbing. What is the priority
differential?
A. Congestive Heart Failure
B. Bronchiectasis
C. Chronic Bronchitis
,D. Lung Cancer
Correct Answer: D
Rationale: Digital clubbing in a chronic smoker with progressive respiratory symptoms is a major red
flag for underlying malignancy. While COPD and chronic bronchitis are common in smokers, they do not
typically cause clubbing without comorbid conditions. Heart failure usually presents with peripheral
edema and paroxysmal nocturnal dyspnea, which are absent here. The clinician must prioritize a chest X-
ray followed by a CT scan for definitive evaluation of lung masses. Early identification of lung cancer is
essential for improving prognosis in high-risk patients.
3. A patient presents with a ‘herald patch’ followed by a generalized ‘Christmas tree’ distribution of smaller
maculopapular lesions on the trunk. What is the most likely diagnosis?
A. Tinea Corporis
B. Secondary Syphilis
C. Pityriasis Rosea
D. Guttate Psoriasis
Correct Answer: C
Rationale: Pityriasis rosea typically begins with a single, larger herald patch before spreading in a
symmetric distribution. The ‘Christmas tree’ pattern follows the cleavage lines of the skin on the torso.
Tinea corporis usually consists of fewer, annular lesions with central clearing and is not widespread.
Secondary syphilis must be ruled out if the palms and soles are involved, but the distribution described is
classic for Pityriasis Rosea. This condition is self-limiting and generally requires only symptomatic
treatment for pruritus.
, 4. A 24-year-old woman complains of fatigue, weight gain, and cold intolerance over the last 6 months.
Physical exam reveals a slow heart rate and delayed deep tendon reflexes. Which lab test is the most
appropriate first step?
A. Serum Cortisol
B. Free T4 only
C. Complete Blood Count (CBC)
D. Thyroid Stimulating Hormone (TSH)
Correct Answer: D
Rationale: The patient’s symptoms are classic indicators of hypothyroidism, which affects multiple
metabolic systems. TSH is the most sensitive screening test for primary thyroid dysfunction in the
primary care setting. If the TSH is elevated, a follow-up Free T4 is used to confirm the diagnosis and
severity. While a CBC could evaluate for anemia-related fatigue, it does not explain the bradycardia or
cold intolerance. Effective management involves levothyroxine replacement and periodic monitoring of
TSH levels.
5. An elderly patient presents with sudden onset of severe eye pain, blurred vision, and seeing ‘halos’
around lights. On exam, the pupil is mid-dilated and non-reactive. What is the immediate action?
A. Prescribe antibiotic eye drops
B. Emergency referral to ophthalmology
C. Apply a warm compress
D. Perform a Fluorescein stain
Correct Answer: B
University Updated and Latest Questions and Correct
Answers with Rationale
1. A 45-year-old female presents with sharp right upper quadrant (RUQ) abdominal pain that radiates to her
right shoulder, occurring primarily after eating fried foods. Which diagnosis is most likely?
A. Acute Pancreatitis
B. Acute Cholecystitis
C. Gastroesophageal Reflux Disease (GERD)
D. Peptic Ulcer Disease
Correct Answer: B
Rationale: The clinical presentation of RUQ pain triggered by fatty meals is highly characteristic of
biliary colic or cholecystitis. Radiation to the right shoulder, known as Boas’ sign, is a common finding in
gallbladder inflammation. Acute pancreatitis usually presents with epigastric pain that radiates to the
back rather than the shoulder. GERD typically presents as retrosternal burning rather than focal RUQ
tenderness. Initial diagnostic imaging should include a right upper quadrant ultrasound to assess for
stones or wall thickening.
2. A 62-year-old male reports a 3-month history of progressive shortness of breath and a persistent dry
cough. He has a 40-pack-year smoking history and shows signs of digital clubbing. What is the priority
differential?
A. Congestive Heart Failure
B. Bronchiectasis
C. Chronic Bronchitis
,D. Lung Cancer
Correct Answer: D
Rationale: Digital clubbing in a chronic smoker with progressive respiratory symptoms is a major red
flag for underlying malignancy. While COPD and chronic bronchitis are common in smokers, they do not
typically cause clubbing without comorbid conditions. Heart failure usually presents with peripheral
edema and paroxysmal nocturnal dyspnea, which are absent here. The clinician must prioritize a chest X-
ray followed by a CT scan for definitive evaluation of lung masses. Early identification of lung cancer is
essential for improving prognosis in high-risk patients.
3. A patient presents with a ‘herald patch’ followed by a generalized ‘Christmas tree’ distribution of smaller
maculopapular lesions on the trunk. What is the most likely diagnosis?
A. Tinea Corporis
B. Secondary Syphilis
C. Pityriasis Rosea
D. Guttate Psoriasis
Correct Answer: C
Rationale: Pityriasis rosea typically begins with a single, larger herald patch before spreading in a
symmetric distribution. The ‘Christmas tree’ pattern follows the cleavage lines of the skin on the torso.
Tinea corporis usually consists of fewer, annular lesions with central clearing and is not widespread.
Secondary syphilis must be ruled out if the palms and soles are involved, but the distribution described is
classic for Pityriasis Rosea. This condition is self-limiting and generally requires only symptomatic
treatment for pruritus.
, 4. A 24-year-old woman complains of fatigue, weight gain, and cold intolerance over the last 6 months.
Physical exam reveals a slow heart rate and delayed deep tendon reflexes. Which lab test is the most
appropriate first step?
A. Serum Cortisol
B. Free T4 only
C. Complete Blood Count (CBC)
D. Thyroid Stimulating Hormone (TSH)
Correct Answer: D
Rationale: The patient’s symptoms are classic indicators of hypothyroidism, which affects multiple
metabolic systems. TSH is the most sensitive screening test for primary thyroid dysfunction in the
primary care setting. If the TSH is elevated, a follow-up Free T4 is used to confirm the diagnosis and
severity. While a CBC could evaluate for anemia-related fatigue, it does not explain the bradycardia or
cold intolerance. Effective management involves levothyroxine replacement and periodic monitoring of
TSH levels.
5. An elderly patient presents with sudden onset of severe eye pain, blurred vision, and seeing ‘halos’
around lights. On exam, the pupil is mid-dilated and non-reactive. What is the immediate action?
A. Prescribe antibiotic eye drops
B. Emergency referral to ophthalmology
C. Apply a warm compress
D. Perform a Fluorescein stain
Correct Answer: B
