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NR 511 Differential Diagnosis & Primary Care
ACTUAL EXAM QUESTIONS AND ANSWERS
2026/2027 | Final Practicum Exam | Chamberlain
University | Pass Guaranteed - A+ Graded
SECTION 1: Complex Differential Diagnosis & Diagnostic Reasoning
Case Study 1 (Questions 1–4): A 52-year-old male construction worker presents with 3 months
of progressive fatigue, 15-pound unintentional weight loss, and dull right upper quadrant pain
that radiates to his back. He reports occasional nausea and has noticed his urine is "tea-colored"
on some mornings. He drinks 2–3 beers nightly and has smoked a pack of cigarettes daily for 30
years. Vital signs: BP 142/88, HR 88, RR 16, Temp 37.2°C. Physical exam reveals mild scleral
icterus, hepatomegaly with a firm, nodular edge palpable 3 cm below the costal margin, and mild
ankle edema bilaterally.
Q1: Based on this presentation, which diagnosis should be prioritized as the most likely in your
differential?
A. Alcoholic hepatitis
B. Hepatocellular carcinoma (HCC) [CORRECT]
C. Metastatic colon cancer
D. Primary biliary cholangitis
Correct Answer: B
Rationale: The constellation of red flag symptoms—unintentional weight loss, RUQ pain with
back radiation, scleral icterus (obstructive jaundice pattern), and a nodular, enlarged liver in a
patient with major risk factors (chronic alcohol use, tobacco use) strongly suggests
hepatocellular carcinoma. While alcoholic hepatitis (A) could explain some findings, the nodular
liver and weight loss are more concerning for malignancy. Metastatic colon cancer (C) typically
presents with GI bleeding, change in bowel habits, or RLQ pain, and would be less likely to
cause early jaundice without significant hepatic involvement. Primary biliary cholangitis (D)
predominantly affects middle-aged women and presents with pruritus and fatigue, not this acute
symptom complex.
Q2: [Select All That Apply] Which diagnostic studies are most appropriate for the initial
workup of this patient?
,2
A. Comprehensive metabolic panel with liver function tests [CORRECT]
B. Alpha-fetoprotein (AFP) tumor marker [CORRECT]
C. Contrast-enhanced CT of the abdomen/pelvis or MRI with Eovist [CORRECT]
D. Screening colonoscopy
E. Hepatitis B and C serologies [CORRECT]
F. CA 19-9 tumor marker
G. Liver biopsy (immediate, before imaging)
Correct Answers: A, B, C, E
Rationale: The initial workup must characterize liver function (A), identify viral etiologies that
increase HCC risk (E), detect HCC-specific markers (AFP—B), and anatomically characterize
the lesion (C—imaging is essential before any invasive procedure). CA 19-9 (F) is more specific
for pancreaticobiliary cancers and is not first-line for suspected HCC. Colonoscopy (D) is
important for cancer screening but does not address the immediate diagnostic priority. Liver
biopsy (G) is contraindicated as an initial step due to risk of seeding the needle tract with
malignant cells; imaging and AFP are preferred first-line diagnostics per AASLD guidelines.
Q3: The CT reveals a 4.2 cm hypervascular mass in the right hepatic lobe with arterial phase
enhancement and portal venous washout, characteristic of HCC. AFP is elevated at 892 ng/mL.
What is the most appropriate next step in management?
A. Immediate surgical resection
B. Referral to a multidisciplinary hepatobiliary tumor board for staging and treatment planning
[CORRECT]
C. Transarterial chemoembolization (TACE)
D. Start sorafenib immediately
Correct Answer: B
Rationale: The diagnosis of HCC is established by imaging criteria (LI-RADS 5) plus elevated
AFP. However, treatment decisions require comprehensive staging (assessment of portal vein
patency, residual liver function, extrahepatic spread) and multidisciplinary input. Resection (A)
is only possible with adequate future liver remnant and absence of cirrhosis decompensation.
TACE (C) and sorafenib (D) are treatment modalities that require proper patient selection based
on Barcelona Clinic Liver Cancer (BCLC) staging. Immediate referral to a tumor board (B)
ensures evidence-based, individualized care.
Q4: [Ordered Response] Place the following management priorities in order for this patient:
1. Smoking cessation counseling [CORRECT]
,3
2. Hepatitis C treatment if positive [CORRECT]
3. Alcohol cessation with referral to treatment [CORRECT]
4. Evaluation for liver transplantation candidacy [CORRECT]
Correct Order: 3, 1, 2, 4 (or 1, 3, 2, 4—both 1 and 3 are immediate lifestyle priorities;
however, alcohol cessation is most critical for liver health preservation)
Rationale: Immediate priorities include alcohol cessation (3—essential to prevent further
hepatic damage and is a requirement for most HCC treatments) and smoking cessation (1—
reduces surgical complications and second primary malignancies). Treating underlying hepatitis
(2) may be possible concurrently depending on liver function. Transplant evaluation (4) is
appropriate for select patients with early-stage HCC and cirrhosis but follows initial staging and
lifestyle modification.
Case Study 2 (Questions 5–8): A 28-year-old female graduate student presents with a 2-week
history of persistent headache, described as "pressure behind my eyes," worse in the morning and
with Valsalva maneuvers. She reports transient visual "gray-outs" lasting 5–10 seconds when
standing quickly, and mild nausea without vomiting. She takes oral contraceptives and has
gained 8 pounds in the past month. Fundoscopic exam reveals bilateral papilledema. Neurologic
exam is otherwise nonfocal. Vital signs: BP 118/74, HR 76, BMI 31.
Q5: Which diagnosis is most likely based on this presentation?
A. Tension-type headache
B. Migraine with aura
C. Idiopathic intracranial hypertension (IIH) [CORRECT]
D. Brain tumor
Correct Answer: C
Rationale: The classic triad of IIH includes headache (often worse with Valsalva/lying flat),
papilledema, and visual disturbances (transient visual obscurations), occurring in an obese
woman of childbearing age with recent weight gain. Oral contraceptives are a known risk
factor. Tension headache (A) and migraine (B) do not cause papilledema. While brain tumor (D)
can cause increased intracranial pressure, the absence of focal neurologic deficits and the specific
demographic profile make IIH more probable; however, neuroimaging is required to exclude
mass lesion.
Q6: What is the most appropriate initial diagnostic study?
, 4
A. Lumbar puncture with opening pressure
B. MRI of the brain with and without contrast, and MR venography [CORRECT]
C. CT angiography of the head and neck
D. Trial of sumatriptan
Correct Answer: B
Rationale: Before diagnosing IIH, secondary causes of increased intracranial pressure must
be excluded, including venous sinus thrombosis, mass lesions, and structural abnormalities. MRI
with MR venography (B) is the preferred initial study to evaluate for these conditions and assess
for empty sella, flattening of posterior globes, and venous sinus stenosis. Lumbar puncture (A) is
diagnostic for IIH (elevated opening pressure >25 cm H₂O) but is performed after neuroimaging
excludes contraindications. CTA (C) evaluates arterial structures, not relevant here. Sumatriptan
(D) is inappropriate given papilledema.
Q7: [Select All That Apply] Which interventions are appropriate first-line management for
this patient?
A. Acetazolamide [CORRECT]
B. Weight loss of 5–10% of body weight [CORRECT]
C. Discontinuation of oral contraceptives [CORRECT]
D. Immediate optic nerve sheath fenestration
E. Topiramate as alternative to acetazolamide [CORRECT]
F. Serial visual field testing [CORRECT]
Correct Answers: A, B, C, E, F
Rationale: First-line management of IIH includes acetazolamide (A—a carbonic anhydrase
inhibitor reducing CSF production), weight loss (B—often curative), and removal of
precipitating medications (C). Topiramate (E) has carbonic anhydrase activity and can serve as
alternative. Visual field monitoring (F) is essential to detect progressive vision loss. Surgical
interventions like optic nerve sheath fenestration (D) are reserved for rapid visual decline or
failed medical therapy.
Q8: The patient reports she is planning pregnancy. Which counseling is most accurate regarding
IIH and pregnancy?
A. Pregnancy is contraindicated with IIH
B. IIH typically worsens significantly during pregnancy and requires therapeutic abortion
C. Most patients with IIH can have successful pregnancies with coordinated obstetric-neurologic
NR 511 Differential Diagnosis & Primary Care
ACTUAL EXAM QUESTIONS AND ANSWERS
2026/2027 | Final Practicum Exam | Chamberlain
University | Pass Guaranteed - A+ Graded
SECTION 1: Complex Differential Diagnosis & Diagnostic Reasoning
Case Study 1 (Questions 1–4): A 52-year-old male construction worker presents with 3 months
of progressive fatigue, 15-pound unintentional weight loss, and dull right upper quadrant pain
that radiates to his back. He reports occasional nausea and has noticed his urine is "tea-colored"
on some mornings. He drinks 2–3 beers nightly and has smoked a pack of cigarettes daily for 30
years. Vital signs: BP 142/88, HR 88, RR 16, Temp 37.2°C. Physical exam reveals mild scleral
icterus, hepatomegaly with a firm, nodular edge palpable 3 cm below the costal margin, and mild
ankle edema bilaterally.
Q1: Based on this presentation, which diagnosis should be prioritized as the most likely in your
differential?
A. Alcoholic hepatitis
B. Hepatocellular carcinoma (HCC) [CORRECT]
C. Metastatic colon cancer
D. Primary biliary cholangitis
Correct Answer: B
Rationale: The constellation of red flag symptoms—unintentional weight loss, RUQ pain with
back radiation, scleral icterus (obstructive jaundice pattern), and a nodular, enlarged liver in a
patient with major risk factors (chronic alcohol use, tobacco use) strongly suggests
hepatocellular carcinoma. While alcoholic hepatitis (A) could explain some findings, the nodular
liver and weight loss are more concerning for malignancy. Metastatic colon cancer (C) typically
presents with GI bleeding, change in bowel habits, or RLQ pain, and would be less likely to
cause early jaundice without significant hepatic involvement. Primary biliary cholangitis (D)
predominantly affects middle-aged women and presents with pruritus and fatigue, not this acute
symptom complex.
Q2: [Select All That Apply] Which diagnostic studies are most appropriate for the initial
workup of this patient?
,2
A. Comprehensive metabolic panel with liver function tests [CORRECT]
B. Alpha-fetoprotein (AFP) tumor marker [CORRECT]
C. Contrast-enhanced CT of the abdomen/pelvis or MRI with Eovist [CORRECT]
D. Screening colonoscopy
E. Hepatitis B and C serologies [CORRECT]
F. CA 19-9 tumor marker
G. Liver biopsy (immediate, before imaging)
Correct Answers: A, B, C, E
Rationale: The initial workup must characterize liver function (A), identify viral etiologies that
increase HCC risk (E), detect HCC-specific markers (AFP—B), and anatomically characterize
the lesion (C—imaging is essential before any invasive procedure). CA 19-9 (F) is more specific
for pancreaticobiliary cancers and is not first-line for suspected HCC. Colonoscopy (D) is
important for cancer screening but does not address the immediate diagnostic priority. Liver
biopsy (G) is contraindicated as an initial step due to risk of seeding the needle tract with
malignant cells; imaging and AFP are preferred first-line diagnostics per AASLD guidelines.
Q3: The CT reveals a 4.2 cm hypervascular mass in the right hepatic lobe with arterial phase
enhancement and portal venous washout, characteristic of HCC. AFP is elevated at 892 ng/mL.
What is the most appropriate next step in management?
A. Immediate surgical resection
B. Referral to a multidisciplinary hepatobiliary tumor board for staging and treatment planning
[CORRECT]
C. Transarterial chemoembolization (TACE)
D. Start sorafenib immediately
Correct Answer: B
Rationale: The diagnosis of HCC is established by imaging criteria (LI-RADS 5) plus elevated
AFP. However, treatment decisions require comprehensive staging (assessment of portal vein
patency, residual liver function, extrahepatic spread) and multidisciplinary input. Resection (A)
is only possible with adequate future liver remnant and absence of cirrhosis decompensation.
TACE (C) and sorafenib (D) are treatment modalities that require proper patient selection based
on Barcelona Clinic Liver Cancer (BCLC) staging. Immediate referral to a tumor board (B)
ensures evidence-based, individualized care.
Q4: [Ordered Response] Place the following management priorities in order for this patient:
1. Smoking cessation counseling [CORRECT]
,3
2. Hepatitis C treatment if positive [CORRECT]
3. Alcohol cessation with referral to treatment [CORRECT]
4. Evaluation for liver transplantation candidacy [CORRECT]
Correct Order: 3, 1, 2, 4 (or 1, 3, 2, 4—both 1 and 3 are immediate lifestyle priorities;
however, alcohol cessation is most critical for liver health preservation)
Rationale: Immediate priorities include alcohol cessation (3—essential to prevent further
hepatic damage and is a requirement for most HCC treatments) and smoking cessation (1—
reduces surgical complications and second primary malignancies). Treating underlying hepatitis
(2) may be possible concurrently depending on liver function. Transplant evaluation (4) is
appropriate for select patients with early-stage HCC and cirrhosis but follows initial staging and
lifestyle modification.
Case Study 2 (Questions 5–8): A 28-year-old female graduate student presents with a 2-week
history of persistent headache, described as "pressure behind my eyes," worse in the morning and
with Valsalva maneuvers. She reports transient visual "gray-outs" lasting 5–10 seconds when
standing quickly, and mild nausea without vomiting. She takes oral contraceptives and has
gained 8 pounds in the past month. Fundoscopic exam reveals bilateral papilledema. Neurologic
exam is otherwise nonfocal. Vital signs: BP 118/74, HR 76, BMI 31.
Q5: Which diagnosis is most likely based on this presentation?
A. Tension-type headache
B. Migraine with aura
C. Idiopathic intracranial hypertension (IIH) [CORRECT]
D. Brain tumor
Correct Answer: C
Rationale: The classic triad of IIH includes headache (often worse with Valsalva/lying flat),
papilledema, and visual disturbances (transient visual obscurations), occurring in an obese
woman of childbearing age with recent weight gain. Oral contraceptives are a known risk
factor. Tension headache (A) and migraine (B) do not cause papilledema. While brain tumor (D)
can cause increased intracranial pressure, the absence of focal neurologic deficits and the specific
demographic profile make IIH more probable; however, neuroimaging is required to exclude
mass lesion.
Q6: What is the most appropriate initial diagnostic study?
, 4
A. Lumbar puncture with opening pressure
B. MRI of the brain with and without contrast, and MR venography [CORRECT]
C. CT angiography of the head and neck
D. Trial of sumatriptan
Correct Answer: B
Rationale: Before diagnosing IIH, secondary causes of increased intracranial pressure must
be excluded, including venous sinus thrombosis, mass lesions, and structural abnormalities. MRI
with MR venography (B) is the preferred initial study to evaluate for these conditions and assess
for empty sella, flattening of posterior globes, and venous sinus stenosis. Lumbar puncture (A) is
diagnostic for IIH (elevated opening pressure >25 cm H₂O) but is performed after neuroimaging
excludes contraindications. CTA (C) evaluates arterial structures, not relevant here. Sumatriptan
(D) is inappropriate given papilledema.
Q7: [Select All That Apply] Which interventions are appropriate first-line management for
this patient?
A. Acetazolamide [CORRECT]
B. Weight loss of 5–10% of body weight [CORRECT]
C. Discontinuation of oral contraceptives [CORRECT]
D. Immediate optic nerve sheath fenestration
E. Topiramate as alternative to acetazolamide [CORRECT]
F. Serial visual field testing [CORRECT]
Correct Answers: A, B, C, E, F
Rationale: First-line management of IIH includes acetazolamide (A—a carbonic anhydrase
inhibitor reducing CSF production), weight loss (B—often curative), and removal of
precipitating medications (C). Topiramate (E) has carbonic anhydrase activity and can serve as
alternative. Visual field monitoring (F) is essential to detect progressive vision loss. Surgical
interventions like optic nerve sheath fenestration (D) are reserved for rapid visual decline or
failed medical therapy.
Q8: The patient reports she is planning pregnancy. Which counseling is most accurate regarding
IIH and pregnancy?
A. Pregnancy is contraindicated with IIH
B. IIH typically worsens significantly during pregnancy and requires therapeutic abortion
C. Most patients with IIH can have successful pregnancies with coordinated obstetric-neurologic
