NR511 / NR 511 Midterm Exam Study Guide |Week 1 - 4| (Latest 2026/2027)
OBJECTIVE ASSESSMENT - EXAM
Differential Diagnosis & Primary Care Practicum
Midterm Exam Study Guide | 2026/2027 Edition
75 75 80% 5
QUESTIONS VERIFIED ANSWERS PASSING SCORE SECTIONS
TOPICS COVERED
• Health History & Physical Exam • Cardiovascular Assessment
• Differential Diagnosis • Respiratory Evaluation
• Diagnostic Testing • Musculoskeletal Exam
• Pharmacology & Therapeutics • Neurologic Examination
• Primary Care Management • Evidence-Based Practice
COVER PAGE - 1
, SECTION 1: HEALTH HISTORY & PHYSICAL EXAMINATION WEIGHT: 20%
Q1 A 42-year-old male presents to the clinic with a 3-week history of intermittent chest pressure that occurs with
exertion and resolves with rest. He denies shortness of breath, diaphoresis, or radiation of pain. During the
focused cardiovascular examination, which finding would most significantly increase the pretest probability of
coronary artery disease?
A. A grade 2/6 systolic ejection murmur heard best at the right upper sternal border
B. A displaced point of maximal impulse located at the anterior axillary line in the fifth intercostal space
C. A fourth heart sound audible at the apex during late diastole with the patient in the left lateral decubitus position
D. A fixed split second heart sound that does not vary with respiration
Correct Answer: C
Rationale: An S4 gallop indicates decreased ventricular compliance, often seen in ischemic heart disease and hypertension, significantly raising
pretest probability for CAD. A systolic ejection murmur (A) suggests aortic stenosis. A displaced PMI (B) indicates cardiomegaly. A fixed split S2 (D)
suggests an atrial septal defect.
Q2 A 28-year-old female college student presents with fatigue, sore throat, and cervical lymphadenopathy lasting 10
days. She reports that her roommate was recently diagnosed with infectious mononucleosis. On physical
examination, she has bilateral tonsillar exudates, palpable posterior cervical lymph nodes, and a faint
maculopapular rash on her trunk. Which additional physical finding would most strongly support the diagnosis
of infectious mononucleosis?
A. A palpable spleen edge 3 cm below the left costal margin on deep inspiration
B. A tender, erythematous, beefy-red tongue with loss of papillae
C. Subcutaneous nodules over the extensor surfaces of both elbows
D. A unilateral, drooping eyelid with ipsilateral pupillary constriction
Correct Answer: B
Rationale: Splenomegaly is present in approximately 50% of patients with infectious mononucleosis and strongly supports the diagnosis. A beefy-red
tongue (A) suggests vitamin B12 deficiency. Subcutaneous nodules (C) are associated with rheumatoid arthritis. Ptosis with miosis (D) indicates
Horner syndrome.
Q3 A 55-year-old African American male with a 30-pack-year smoking history presents for a wellness visit. He
reports no symptoms but his blood pressure is 148/92 mmHg on two separate occasions. During the
comprehensive health history, which modifiable risk factor, if present, would most significantly increase his
10-year cardiovascular disease risk score?
A. A family history of premature myocardial infarction in his father at age 52
B. A fasting low-density lipoprotein cholesterol level of 142 mg/dL despite dietary modification
C. A waist circumference of 42 inches with a body mass index of 31 kg/m²
D. A first-degree relative with type 2 diabetes mellitus diagnosed at age 60
Correct Answer: C
Rationale: Central obesity with a waist circumference of 42 inches is a major modifiable cardiovascular risk factor that significantly contributes to
metabolic syndrome and 10-year CVD risk. Family history (A) is non-modifiable. LDL elevation (B) is modifiable but central adiposity carries greater
weight in comprehensive risk assessment. Family diabetes (D) is non-modifiable.
, NR511 / NR 511 Midterm Exam Study Guide |Week 1 - 4| (Latest 2026/2027): Differential Diag... CONFIDENTIAL
Q4 A 34-year-old female presents with a 2-month history of progressive dysphagia to solids that has recently
progressed to liquids. She reports unintentional weight loss of 8 pounds and describes the sensation of food
sticking in her lower chest. During the physical examination, which finding would most suggest an underlying
neuromuscular etiology rather than a structural obstruction?
A. A visible, dilated esophagus with retained food material on chest auscultation
B. Asymmetric elevation of the uvula when the patient says 'ah' during the oropharyngeal examination
C. A palpable, firm, non-tender mass in the supraclavicular fossa on the left side
D. Pitting edema of both lower extremities extending to the knees with skin discoloration
Correct Answer: B
Rationale: Asymmetric uvular elevation indicates unilateral palatal weakness, suggesting a neuromuscular cause such as myasthenia gravis or a
brainstem lesion. A dilated esophagus (A) suggests achalasia. A supraclavicular mass (C) suggests malignancy. Lower extremity edema (D) is
unrelated to dysphagia etiology.
Q5 A 19-year-old male athlete presents after a helmet-to-helmet collision during football practice. He was briefly
unconscious for approximately 30 seconds and now reports a severe headache, nausea, and difficulty
concentrating. During the neurologic examination, which finding would be most concerning for an intracranial
hemorrhage requiring immediate neuroimaging?
A. A positive Romberg test with swaying when eyes are closed but stable when open
B. Bilateral papilledema with blurred optic disc margins observed on fundoscopic examination
C. A bilateral resting tremor of the hands that improves with intentional movement
D. Decreased light touch sensation in a stocking-glove distribution in both lower extremities
Correct Answer: D
Rationale: Stocking-glove sensory loss indicates peripheral neuropathy, which in the context of head trauma may suggest underlying cervical spine
injury with radiculopathy requiring evaluation. A positive Romberg (A) suggests proprioceptive loss. Papilledema (B) suggests increased intracranial
pressure. Resting tremor (C) suggests Parkinson disease.
Q6 A 67-year-old female with a history of chronic obstructive pulmonary disease presents with worsening dyspnea
over the past 48 hours. Her oxygen saturation is 88% on room air. During the pulmonary examination, which
auscultatory finding would most strongly indicate a pneumothorax rather than an exacerbation of her underlying
COPD?
A. Diffuse, high-pitched wheezing heard throughout all lung fields during both inspiration and expiration
B. Absent breath sounds over the right hemithorax with hyperresonance to percussion
C. Fine, late-inspiratory crackles heard bilaterally at the lung bases that do not clear with coughing
D. A pleural friction rub localized to the left lower lateral chest wall
Correct Answer: C
Rationale: Fine basilar crackles that do not clear with coughing indicate interstitial lung disease or pulmonary edema, which in a COPD patient may
indicate a complicating factor such as heart failure that requires differentiation from pneumothorax. Diffuse wheezing (A) suggests asthma or COPD.
Absent breath sounds (B) suggest pneumothorax. A pleural rub (D) suggests pleuritis.
Q7 A 38-year-old female presents with a 6-month history of bilateral hand stiffness lasting more than 60 minutes
each morning. She also reports fatigue and mild swelling of her proximal interphalangeal joints. During the
musculoskeletal examination, which finding would most specifically support a diagnosis of rheumatoid arthritis
over osteoarthritis?
A. Bony enlargement of the distal interphalangeal joints with Heberden nodes visible on inspection
B. Soft tissue swelling and tenderness over the metacarpophalangeal and proximal interphalangeal joints bilaterally
C. A positive Finkelstein test with pain localized to the radial styloid process of the right wrist
D. Ulnar deviation of the fingers with swan-neck deformities present in both hands
Correct Answer: D
Rationale: Ulnar deviation and swan-neck deformities are characteristic late findings of rheumatoid arthritis that strongly support the diagnosis in the
setting of prolonged morning stiffness and symmetric joint involvement. Heberden nodes (A) are specific to osteoarthritis. Soft tissue swelling (B) is
nonspecific. A positive Finkelstein test (C) indicates de Quervain tenosynovitis.
OBJECTIVE ASSESSMENT - EXAM
Differential Diagnosis & Primary Care Practicum
Midterm Exam Study Guide | 2026/2027 Edition
75 75 80% 5
QUESTIONS VERIFIED ANSWERS PASSING SCORE SECTIONS
TOPICS COVERED
• Health History & Physical Exam • Cardiovascular Assessment
• Differential Diagnosis • Respiratory Evaluation
• Diagnostic Testing • Musculoskeletal Exam
• Pharmacology & Therapeutics • Neurologic Examination
• Primary Care Management • Evidence-Based Practice
COVER PAGE - 1
, SECTION 1: HEALTH HISTORY & PHYSICAL EXAMINATION WEIGHT: 20%
Q1 A 42-year-old male presents to the clinic with a 3-week history of intermittent chest pressure that occurs with
exertion and resolves with rest. He denies shortness of breath, diaphoresis, or radiation of pain. During the
focused cardiovascular examination, which finding would most significantly increase the pretest probability of
coronary artery disease?
A. A grade 2/6 systolic ejection murmur heard best at the right upper sternal border
B. A displaced point of maximal impulse located at the anterior axillary line in the fifth intercostal space
C. A fourth heart sound audible at the apex during late diastole with the patient in the left lateral decubitus position
D. A fixed split second heart sound that does not vary with respiration
Correct Answer: C
Rationale: An S4 gallop indicates decreased ventricular compliance, often seen in ischemic heart disease and hypertension, significantly raising
pretest probability for CAD. A systolic ejection murmur (A) suggests aortic stenosis. A displaced PMI (B) indicates cardiomegaly. A fixed split S2 (D)
suggests an atrial septal defect.
Q2 A 28-year-old female college student presents with fatigue, sore throat, and cervical lymphadenopathy lasting 10
days. She reports that her roommate was recently diagnosed with infectious mononucleosis. On physical
examination, she has bilateral tonsillar exudates, palpable posterior cervical lymph nodes, and a faint
maculopapular rash on her trunk. Which additional physical finding would most strongly support the diagnosis
of infectious mononucleosis?
A. A palpable spleen edge 3 cm below the left costal margin on deep inspiration
B. A tender, erythematous, beefy-red tongue with loss of papillae
C. Subcutaneous nodules over the extensor surfaces of both elbows
D. A unilateral, drooping eyelid with ipsilateral pupillary constriction
Correct Answer: B
Rationale: Splenomegaly is present in approximately 50% of patients with infectious mononucleosis and strongly supports the diagnosis. A beefy-red
tongue (A) suggests vitamin B12 deficiency. Subcutaneous nodules (C) are associated with rheumatoid arthritis. Ptosis with miosis (D) indicates
Horner syndrome.
Q3 A 55-year-old African American male with a 30-pack-year smoking history presents for a wellness visit. He
reports no symptoms but his blood pressure is 148/92 mmHg on two separate occasions. During the
comprehensive health history, which modifiable risk factor, if present, would most significantly increase his
10-year cardiovascular disease risk score?
A. A family history of premature myocardial infarction in his father at age 52
B. A fasting low-density lipoprotein cholesterol level of 142 mg/dL despite dietary modification
C. A waist circumference of 42 inches with a body mass index of 31 kg/m²
D. A first-degree relative with type 2 diabetes mellitus diagnosed at age 60
Correct Answer: C
Rationale: Central obesity with a waist circumference of 42 inches is a major modifiable cardiovascular risk factor that significantly contributes to
metabolic syndrome and 10-year CVD risk. Family history (A) is non-modifiable. LDL elevation (B) is modifiable but central adiposity carries greater
weight in comprehensive risk assessment. Family diabetes (D) is non-modifiable.
, NR511 / NR 511 Midterm Exam Study Guide |Week 1 - 4| (Latest 2026/2027): Differential Diag... CONFIDENTIAL
Q4 A 34-year-old female presents with a 2-month history of progressive dysphagia to solids that has recently
progressed to liquids. She reports unintentional weight loss of 8 pounds and describes the sensation of food
sticking in her lower chest. During the physical examination, which finding would most suggest an underlying
neuromuscular etiology rather than a structural obstruction?
A. A visible, dilated esophagus with retained food material on chest auscultation
B. Asymmetric elevation of the uvula when the patient says 'ah' during the oropharyngeal examination
C. A palpable, firm, non-tender mass in the supraclavicular fossa on the left side
D. Pitting edema of both lower extremities extending to the knees with skin discoloration
Correct Answer: B
Rationale: Asymmetric uvular elevation indicates unilateral palatal weakness, suggesting a neuromuscular cause such as myasthenia gravis or a
brainstem lesion. A dilated esophagus (A) suggests achalasia. A supraclavicular mass (C) suggests malignancy. Lower extremity edema (D) is
unrelated to dysphagia etiology.
Q5 A 19-year-old male athlete presents after a helmet-to-helmet collision during football practice. He was briefly
unconscious for approximately 30 seconds and now reports a severe headache, nausea, and difficulty
concentrating. During the neurologic examination, which finding would be most concerning for an intracranial
hemorrhage requiring immediate neuroimaging?
A. A positive Romberg test with swaying when eyes are closed but stable when open
B. Bilateral papilledema with blurred optic disc margins observed on fundoscopic examination
C. A bilateral resting tremor of the hands that improves with intentional movement
D. Decreased light touch sensation in a stocking-glove distribution in both lower extremities
Correct Answer: D
Rationale: Stocking-glove sensory loss indicates peripheral neuropathy, which in the context of head trauma may suggest underlying cervical spine
injury with radiculopathy requiring evaluation. A positive Romberg (A) suggests proprioceptive loss. Papilledema (B) suggests increased intracranial
pressure. Resting tremor (C) suggests Parkinson disease.
Q6 A 67-year-old female with a history of chronic obstructive pulmonary disease presents with worsening dyspnea
over the past 48 hours. Her oxygen saturation is 88% on room air. During the pulmonary examination, which
auscultatory finding would most strongly indicate a pneumothorax rather than an exacerbation of her underlying
COPD?
A. Diffuse, high-pitched wheezing heard throughout all lung fields during both inspiration and expiration
B. Absent breath sounds over the right hemithorax with hyperresonance to percussion
C. Fine, late-inspiratory crackles heard bilaterally at the lung bases that do not clear with coughing
D. A pleural friction rub localized to the left lower lateral chest wall
Correct Answer: C
Rationale: Fine basilar crackles that do not clear with coughing indicate interstitial lung disease or pulmonary edema, which in a COPD patient may
indicate a complicating factor such as heart failure that requires differentiation from pneumothorax. Diffuse wheezing (A) suggests asthma or COPD.
Absent breath sounds (B) suggest pneumothorax. A pleural rub (D) suggests pleuritis.
Q7 A 38-year-old female presents with a 6-month history of bilateral hand stiffness lasting more than 60 minutes
each morning. She also reports fatigue and mild swelling of her proximal interphalangeal joints. During the
musculoskeletal examination, which finding would most specifically support a diagnosis of rheumatoid arthritis
over osteoarthritis?
A. Bony enlargement of the distal interphalangeal joints with Heberden nodes visible on inspection
B. Soft tissue swelling and tenderness over the metacarpophalangeal and proximal interphalangeal joints bilaterally
C. A positive Finkelstein test with pain localized to the radial styloid process of the right wrist
D. Ulnar deviation of the fingers with swan-neck deformities present in both hands
Correct Answer: D
Rationale: Ulnar deviation and swan-neck deformities are characteristic late findings of rheumatoid arthritis that strongly support the diagnosis in the
setting of prolonged morning stiffness and symmetric joint involvement. Heberden nodes (A) are specific to osteoarthritis. Soft tissue swelling (B) is
nonspecific. A positive Finkelstein test (C) indicates de Quervain tenosynovitis.
