NUR 504 Exam 4: Advanced Health Assessment
and Differential Diagnosis - St. Thomas University
Updated and Latest Questions and Correct
Answers with Rationale
1. A 68-year-old male presents with sudden onset of shortness of breath, orthopnea, and an
audible S3 heart sound. Which of the following is the most likely primary differential
diagnosis?
A. Pulmonary Embolism
B. Chronic Obstructive Pulmonary Disease
C. Acute Heart Failure
D. Pneumonia
Correct Answer: C
Rationale: The patient’s presentation of sudden orthopnea and shortness of breath is
characteristic of acute decompensated heart failure. The presence of an S3 gallop is a highly
specific physical exam finding indicating ventricular volume overload. While COPD can
cause dyspnea, it does not typically present with an S3 heart sound or acute orthopnea.
Pulmonary embolism usually presents with pleuritic chest pain and tachycardia rather
than signs of fluid overload. Diagnostic reasoning prioritizes heart failure based on the
combination of hemodynamic symptoms and auscultatory findings.
2. When interpreting laboratory results, a patient exhibits a Thyroid Stimulating Hormone
(TSH) level of 12.5 mIU/L and a free T4 of 0.6 ng/dL. What is the most appropriate diagnosis?
A. Primary Hypothyroidism
B. Subclinical Hyperthyroidism
C. Secondary Hypothyroidism
D. Euthyroid Sick Syndrome
Correct Answer: A
Rationale: The elevated TSH level combined with a low free T4 level is diagnostic for
primary hypothyroidism. This pattern indicates that the pituitary gland is attempting to
stimulate a non-responsive thyroid gland. Subclinical hypothyroidism would show a high
TSH with a normal free T4 level. Secondary hypothyroidism would typically present with a
low or inappropriately normal TSH and low T4. Clinicians must distinguish these patterns
to initiate the correct hormone replacement therapy.
,3. A 45-year-old female complains of severe right upper quadrant (RUQ) pain that radiates to
the right scapula, especially after eating a fatty meal. A positive Murphy’s sign is noted on
exam. What is the most likely diagnosis?
A. Acute Pancreatitis
B. Peptic Ulcer Disease
C. Gastroesophageal Reflux Disease
D. Acute Cholecystitis
Correct Answer: D
Rationale: The clinical presentation of RUQ pain radiating to the shoulder after fatty meals
is highly suggestive of gallbladder disease. A positive Murphy’s sign, where inspiration is
inhibited by pain during RUQ palpation, is a classic indicator of cholecystitis. Pancreatitis
would more likely present with epigastric pain radiating to the back and elevated lipase
levels. Peptic ulcer disease often involves burning pain that may be relieved by food or
antacids. Diagnostic confirmation typically requires an ultrasound to visualize gallbladder
wall thickening or stones.
4. During a physical exam, you perform the Lachman test on a patient who sustained a knee
injury during soccer. The test shows significant laxity. This finding is most indicative of an
injury to which structure?
A. Anterior Cruciate Ligament (ACL)
B. Posterior Cruciate Ligament (PCL)
C. Medial Collateral Ligament (MCL)
D. Lateral Meniscus
Correct Answer: A
Rationale: The Lachman test is considered the most sensitive physical examination
maneuver for detecting an ACL tear. It involves stabilizing the femur and pulling the tibia
forward with the knee flexed at 20 to 30 degrees. Significant forward displacement of the
tibia without a firm endpoint indicates a positive result. MCL injuries are better assessed
with valgus stress tests rather than anterior translation. Accurate orthopedic assessment is
crucial for determining whether surgical intervention or physical therapy is the priority.
5. A 72-year-old patient presents with new-onset atrial fibrillation and a rapid ventricular
response. Which initial laboratory test is most critical to rule out a common reversible
metabolic cause?
A. Hemoglobin A1c
B. Serum Creatinine
C. Thyroid Stimulating Hormone (TSH)
, D. Troponin I
Correct Answer: C
Rationale: Hyperthyroidism is a well-known reversible cause of new-onset atrial
fibrillation, particularly in the geriatric population. TSH testing is essential to evaluate
thyroid function as a driver of cardiac arrhythmias. While troponin levels are important to
rule out ischemia, they do not identify the metabolic cause of the rhythm change.
Hemoglobin A1c assesses long-term glucose control but is not directly linked to acute
rhythm disturbances. Assessing thyroid status allows for targeted treatment that may
restore normal sinus rhythm without long-term anticoagulation.
6. An 18-year-old male presents with periumbilical pain that has shifted to the right lower
quadrant (RLQ), accompanied by a low-grade fever and nausea. Which physical exam sign
would most likely be positive?
A. Cullen’s Sign
B. Grey Turner’s Sign
C. McBurney’s Point Tenderness
D. Homans’ Sign
Correct Answer: C
Rationale: The migration of pain from the periumbilical region to the RLQ is the classic
presentation of acute appendicitis. McBurney’s point tenderness is the most reliable
clinical indicator of inflammation at the base of the appendix. Cullen’s and Grey Turner’s
signs are associated with retroperitoneal hemorrhage and pancreatitis rather than
appendicitis. Homans’ sign is a dated and unreliable test for deep vein thrombosis in the
lower extremities. Timely identification of these signs is critical to prevent appendiceal
rupture and peritonitis.
7. A 55-year-old smoker presents with a chronic cough and recent hemoptysis. A chest X-ray
reveals a hiliar mass. Which next step is most appropriate for definitive diagnosis?
A. Sputum Culture
B. Pulmonary Function Tests
C. Repeat Chest X-ray in 6 months
D. CT-guided Biopsy or Bronchoscopy
Correct Answer: D
Rationale: The presence of a hilar mass in a long-term smoker with hemoptysis strongly
suggests a pulmonary malignancy. CT imaging or bronchoscopy with biopsy is necessary to
obtain tissue for histological diagnosis. Sputum cultures are used for infections but do not
provide definitive evidence for or against cancer. Pulmonary function tests assess lung
and Differential Diagnosis - St. Thomas University
Updated and Latest Questions and Correct
Answers with Rationale
1. A 68-year-old male presents with sudden onset of shortness of breath, orthopnea, and an
audible S3 heart sound. Which of the following is the most likely primary differential
diagnosis?
A. Pulmonary Embolism
B. Chronic Obstructive Pulmonary Disease
C. Acute Heart Failure
D. Pneumonia
Correct Answer: C
Rationale: The patient’s presentation of sudden orthopnea and shortness of breath is
characteristic of acute decompensated heart failure. The presence of an S3 gallop is a highly
specific physical exam finding indicating ventricular volume overload. While COPD can
cause dyspnea, it does not typically present with an S3 heart sound or acute orthopnea.
Pulmonary embolism usually presents with pleuritic chest pain and tachycardia rather
than signs of fluid overload. Diagnostic reasoning prioritizes heart failure based on the
combination of hemodynamic symptoms and auscultatory findings.
2. When interpreting laboratory results, a patient exhibits a Thyroid Stimulating Hormone
(TSH) level of 12.5 mIU/L and a free T4 of 0.6 ng/dL. What is the most appropriate diagnosis?
A. Primary Hypothyroidism
B. Subclinical Hyperthyroidism
C. Secondary Hypothyroidism
D. Euthyroid Sick Syndrome
Correct Answer: A
Rationale: The elevated TSH level combined with a low free T4 level is diagnostic for
primary hypothyroidism. This pattern indicates that the pituitary gland is attempting to
stimulate a non-responsive thyroid gland. Subclinical hypothyroidism would show a high
TSH with a normal free T4 level. Secondary hypothyroidism would typically present with a
low or inappropriately normal TSH and low T4. Clinicians must distinguish these patterns
to initiate the correct hormone replacement therapy.
,3. A 45-year-old female complains of severe right upper quadrant (RUQ) pain that radiates to
the right scapula, especially after eating a fatty meal. A positive Murphy’s sign is noted on
exam. What is the most likely diagnosis?
A. Acute Pancreatitis
B. Peptic Ulcer Disease
C. Gastroesophageal Reflux Disease
D. Acute Cholecystitis
Correct Answer: D
Rationale: The clinical presentation of RUQ pain radiating to the shoulder after fatty meals
is highly suggestive of gallbladder disease. A positive Murphy’s sign, where inspiration is
inhibited by pain during RUQ palpation, is a classic indicator of cholecystitis. Pancreatitis
would more likely present with epigastric pain radiating to the back and elevated lipase
levels. Peptic ulcer disease often involves burning pain that may be relieved by food or
antacids. Diagnostic confirmation typically requires an ultrasound to visualize gallbladder
wall thickening or stones.
4. During a physical exam, you perform the Lachman test on a patient who sustained a knee
injury during soccer. The test shows significant laxity. This finding is most indicative of an
injury to which structure?
A. Anterior Cruciate Ligament (ACL)
B. Posterior Cruciate Ligament (PCL)
C. Medial Collateral Ligament (MCL)
D. Lateral Meniscus
Correct Answer: A
Rationale: The Lachman test is considered the most sensitive physical examination
maneuver for detecting an ACL tear. It involves stabilizing the femur and pulling the tibia
forward with the knee flexed at 20 to 30 degrees. Significant forward displacement of the
tibia without a firm endpoint indicates a positive result. MCL injuries are better assessed
with valgus stress tests rather than anterior translation. Accurate orthopedic assessment is
crucial for determining whether surgical intervention or physical therapy is the priority.
5. A 72-year-old patient presents with new-onset atrial fibrillation and a rapid ventricular
response. Which initial laboratory test is most critical to rule out a common reversible
metabolic cause?
A. Hemoglobin A1c
B. Serum Creatinine
C. Thyroid Stimulating Hormone (TSH)
, D. Troponin I
Correct Answer: C
Rationale: Hyperthyroidism is a well-known reversible cause of new-onset atrial
fibrillation, particularly in the geriatric population. TSH testing is essential to evaluate
thyroid function as a driver of cardiac arrhythmias. While troponin levels are important to
rule out ischemia, they do not identify the metabolic cause of the rhythm change.
Hemoglobin A1c assesses long-term glucose control but is not directly linked to acute
rhythm disturbances. Assessing thyroid status allows for targeted treatment that may
restore normal sinus rhythm without long-term anticoagulation.
6. An 18-year-old male presents with periumbilical pain that has shifted to the right lower
quadrant (RLQ), accompanied by a low-grade fever and nausea. Which physical exam sign
would most likely be positive?
A. Cullen’s Sign
B. Grey Turner’s Sign
C. McBurney’s Point Tenderness
D. Homans’ Sign
Correct Answer: C
Rationale: The migration of pain from the periumbilical region to the RLQ is the classic
presentation of acute appendicitis. McBurney’s point tenderness is the most reliable
clinical indicator of inflammation at the base of the appendix. Cullen’s and Grey Turner’s
signs are associated with retroperitoneal hemorrhage and pancreatitis rather than
appendicitis. Homans’ sign is a dated and unreliable test for deep vein thrombosis in the
lower extremities. Timely identification of these signs is critical to prevent appendiceal
rupture and peritonitis.
7. A 55-year-old smoker presents with a chronic cough and recent hemoptysis. A chest X-ray
reveals a hiliar mass. Which next step is most appropriate for definitive diagnosis?
A. Sputum Culture
B. Pulmonary Function Tests
C. Repeat Chest X-ray in 6 months
D. CT-guided Biopsy or Bronchoscopy
Correct Answer: D
Rationale: The presence of a hilar mass in a long-term smoker with hemoptysis strongly
suggests a pulmonary malignancy. CT imaging or bronchoscopy with biopsy is necessary to
obtain tissue for histological diagnosis. Sputum cultures are used for infections but do not
provide definitive evidence for or against cancer. Pulmonary function tests assess lung
