1
NURS 8026 DIFFERENTIAL DIAGNOSIS — EXAM 3 RAPID
REVIEW
2026 Update | Complete Solutions | High-Yield Clinical Study
Guide
PART A: CLINICAL CONCEPT DRILL (Questions 1–20)
Question 1 A 28-year-old man presents with periumbilical pain that migrated to the RLQ over 12
hours, accompanied by anorexia and low-grade fever. On exam, you note RLQ tenderness with
guarding. Which physical exam finding is most specific for appendicitis?
A. Rovsing's sign
B. Psoas sign
C. Obturator sign
D. McBurney's point tenderness
Answer: D. McBurney's point tenderness
Explanation: McBurney's point tenderness (located 1/3 of the distance from the ASIS to the
umbilicus) is the most specific physical exam finding for appendicitis. Rovsing's sign (palpation of
LLQ causing RLQ pain), psoas sign (pain with passive extension of the right hip), and obturator
sign (pain with internal rotation of the flexed right hip) are all supportive but less specific. The
classic triad remains: migration of pain from periumbilical to RLQ, anorexia, and fever.
High-Yield Pearl: Migration of pain from periumbilical to RLQ is the single most reliable historical
feature of appendicitis—if the patient tells you this, appendicitis tops your differential until
proven otherwise.
Question 2 A 42-year-old woman with a history of gallstones presents with RUQ pain, fever to
101.2°F, and nausea. On exam, she has inspiratory arrest during deep palpation of the RUQ.
What is the gold-standard initial imaging study?
A. CT abdomen with contrast
B. Right upper quadrant ultrasound
C. HIDA scan
D. MRCP
,2
Answer: B. Right upper quadrant ultrasound
Explanation: RUQ ultrasound is the first-line imaging for suspected acute cholecystitis. Findings
include gallstones, gallbladder wall thickening (>4 mm), pericholecystic fluid, and a sonographic
Murphy's sign (inspiratory arrest with probe pressure). CT is less sensitive for gallstones. HIDA
scan is reserved for equivocal cases when ultrasound is inconclusive. MRCP evaluates the biliary
tree for choledocholithiasis.
High-Yield Pearl: A positive sonographic Murphy's sign + gallstones on ultrasound = acute
cholecystitis with >90% diagnostic accuracy—no further imaging needed.
Question 3 A 38-year-old alcoholic man presents with severe epigastric pain radiating to the
back, nausea, and vomiting. Labs show amylase 420 U/L and lipase 890 U/L. What is the most
common etiology of acute pancreatitis overall?
A. Alcohol abuse
B. Gallstones
C. Hypertriglyceridemia
D. Medications
Answer: B. Gallstones
Explanation: While alcohol is the most common cause in this demographic, gallstones are the
leading cause of acute pancreatitis overall in the United States (approximately 40% of cases).
The classic presentation includes severe epigastric pain radiating to the back, nausea/vomiting,
and elevated lipase >3x upper limit of normal. Lipase is more specific than amylase. Remember
"I GET SMASHED" for causes: Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps,
Autoimmune, Scorpion sting, Hyperlipidemia/Hypercalcemia, ERCP, Drugs.
High-Yield Pearl: Lipase >3x normal in a patient with epigastric pain radiating to the back =
pancreatitis until proven otherwise; gallstones and alcohol account for ~80% of all cases.
Question 4 A 65-year-old man presents with colicky abdominal pain, abdominal distention, and
obstipation. Abdominal X-ray shows dilated loops of small bowel with multiple air-fluid levels.
What is the most common cause of small bowel obstruction in adults without prior abdominal
surgery?
A. Adhesions
B. Hernia
, 3
C. Gallstone ileus
D. Intussusception
Answer: B. Hernia
Explanation: In adults without prior abdominal surgery, hernias (incarcerated/strangulated) are
the most common cause of small bowel obstruction. However, in the general adult population
(including post-surgical patients), adhesions from prior surgery are the leading cause (~60%).
The classic presentation is the "4 D's": Distention, Discomfort, Dehydration, and
Delayed/Diminished flatus. CT with IV contrast is the gold standard for diagnosis and can
identify transition points and complications (strangulation, ischemia).
High-Yield Pearl: If the patient has had prior abdominal surgery, think adhesions first; if no prior
surgery, think hernia first—this distinction is board-exam gold.
Question 5 A 55-year-old man with a history of NSAID use presents with sudden onset of severe
epigastric pain. On exam, he has board-like abdominal rigidity and absent bowel sounds.
Upright chest X-ray shows free air under the diaphragm. What is the immediate next step in
management?
A. Upper endoscopy
B. Emergent surgical consultation
C. CT abdomen with oral contrast
D. IV PPI and observation
Answer: B. Emergent surgical consultation
Explanation: This is a perforated peptic ulcer—a surgical emergency. The classic triad is sudden
severe epigastric pain, rigid abdomen, and free air under the diaphragm on upright CXR
(sensitivity ~75%). Management requires immediate NPO status, IV fluids, broad-spectrum
antibiotics, IV PPI, and emergent surgical consultation. Endoscopy is contraindicated in
perforation. Mortality increases significantly with delay.
High-Yield Pearl: Free air under the diaphragm + rigid abdomen = perforated viscus; this is not a
"watch and wait" diagnosis—surgical consult immediately.
Question 6 A 24-year-old woman presents with chronic diarrhea, weight loss, and fatigue.
Colonoscopy shows skip lesions with cobblestoning, transmural inflammation, and noncaseating
granulomas on biopsy. What is the most likely diagnosis?
NURS 8026 DIFFERENTIAL DIAGNOSIS — EXAM 3 RAPID
REVIEW
2026 Update | Complete Solutions | High-Yield Clinical Study
Guide
PART A: CLINICAL CONCEPT DRILL (Questions 1–20)
Question 1 A 28-year-old man presents with periumbilical pain that migrated to the RLQ over 12
hours, accompanied by anorexia and low-grade fever. On exam, you note RLQ tenderness with
guarding. Which physical exam finding is most specific for appendicitis?
A. Rovsing's sign
B. Psoas sign
C. Obturator sign
D. McBurney's point tenderness
Answer: D. McBurney's point tenderness
Explanation: McBurney's point tenderness (located 1/3 of the distance from the ASIS to the
umbilicus) is the most specific physical exam finding for appendicitis. Rovsing's sign (palpation of
LLQ causing RLQ pain), psoas sign (pain with passive extension of the right hip), and obturator
sign (pain with internal rotation of the flexed right hip) are all supportive but less specific. The
classic triad remains: migration of pain from periumbilical to RLQ, anorexia, and fever.
High-Yield Pearl: Migration of pain from periumbilical to RLQ is the single most reliable historical
feature of appendicitis—if the patient tells you this, appendicitis tops your differential until
proven otherwise.
Question 2 A 42-year-old woman with a history of gallstones presents with RUQ pain, fever to
101.2°F, and nausea. On exam, she has inspiratory arrest during deep palpation of the RUQ.
What is the gold-standard initial imaging study?
A. CT abdomen with contrast
B. Right upper quadrant ultrasound
C. HIDA scan
D. MRCP
,2
Answer: B. Right upper quadrant ultrasound
Explanation: RUQ ultrasound is the first-line imaging for suspected acute cholecystitis. Findings
include gallstones, gallbladder wall thickening (>4 mm), pericholecystic fluid, and a sonographic
Murphy's sign (inspiratory arrest with probe pressure). CT is less sensitive for gallstones. HIDA
scan is reserved for equivocal cases when ultrasound is inconclusive. MRCP evaluates the biliary
tree for choledocholithiasis.
High-Yield Pearl: A positive sonographic Murphy's sign + gallstones on ultrasound = acute
cholecystitis with >90% diagnostic accuracy—no further imaging needed.
Question 3 A 38-year-old alcoholic man presents with severe epigastric pain radiating to the
back, nausea, and vomiting. Labs show amylase 420 U/L and lipase 890 U/L. What is the most
common etiology of acute pancreatitis overall?
A. Alcohol abuse
B. Gallstones
C. Hypertriglyceridemia
D. Medications
Answer: B. Gallstones
Explanation: While alcohol is the most common cause in this demographic, gallstones are the
leading cause of acute pancreatitis overall in the United States (approximately 40% of cases).
The classic presentation includes severe epigastric pain radiating to the back, nausea/vomiting,
and elevated lipase >3x upper limit of normal. Lipase is more specific than amylase. Remember
"I GET SMASHED" for causes: Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps,
Autoimmune, Scorpion sting, Hyperlipidemia/Hypercalcemia, ERCP, Drugs.
High-Yield Pearl: Lipase >3x normal in a patient with epigastric pain radiating to the back =
pancreatitis until proven otherwise; gallstones and alcohol account for ~80% of all cases.
Question 4 A 65-year-old man presents with colicky abdominal pain, abdominal distention, and
obstipation. Abdominal X-ray shows dilated loops of small bowel with multiple air-fluid levels.
What is the most common cause of small bowel obstruction in adults without prior abdominal
surgery?
A. Adhesions
B. Hernia
, 3
C. Gallstone ileus
D. Intussusception
Answer: B. Hernia
Explanation: In adults without prior abdominal surgery, hernias (incarcerated/strangulated) are
the most common cause of small bowel obstruction. However, in the general adult population
(including post-surgical patients), adhesions from prior surgery are the leading cause (~60%).
The classic presentation is the "4 D's": Distention, Discomfort, Dehydration, and
Delayed/Diminished flatus. CT with IV contrast is the gold standard for diagnosis and can
identify transition points and complications (strangulation, ischemia).
High-Yield Pearl: If the patient has had prior abdominal surgery, think adhesions first; if no prior
surgery, think hernia first—this distinction is board-exam gold.
Question 5 A 55-year-old man with a history of NSAID use presents with sudden onset of severe
epigastric pain. On exam, he has board-like abdominal rigidity and absent bowel sounds.
Upright chest X-ray shows free air under the diaphragm. What is the immediate next step in
management?
A. Upper endoscopy
B. Emergent surgical consultation
C. CT abdomen with oral contrast
D. IV PPI and observation
Answer: B. Emergent surgical consultation
Explanation: This is a perforated peptic ulcer—a surgical emergency. The classic triad is sudden
severe epigastric pain, rigid abdomen, and free air under the diaphragm on upright CXR
(sensitivity ~75%). Management requires immediate NPO status, IV fluids, broad-spectrum
antibiotics, IV PPI, and emergent surgical consultation. Endoscopy is contraindicated in
perforation. Mortality increases significantly with delay.
High-Yield Pearl: Free air under the diaphragm + rigid abdomen = perforated viscus; this is not a
"watch and wait" diagnosis—surgical consult immediately.
Question 6 A 24-year-old woman presents with chronic diarrhea, weight loss, and fatigue.
Colonoscopy shows skip lesions with cobblestoning, transmural inflammation, and noncaseating
granulomas on biopsy. What is the most likely diagnosis?
