1 A 45-year-old male comes to the clinic with a chief complaint QUESTION 1 A 45-year-old male comes to the clinic with a chief complaint of epigastric abdominal pain that has persisted for 2 weeks. He describes the pain as burning, non-radiating and is worse after meals. Also, he denies nausea, vomiting, weight loss or obvious bleeding. Finally, he admits to bloating and frequent belching. PMH-+ for osteoarthritis, seasonal allergies with frequent sinusitis infections. Meds-Zyrtec 10 mg po daily and takes it year-round, ibuprofen 400-600 mg po prn pain Family Hx-non contributary Social history-recently divorced and expressed concern at how expensive it is to support 2 homes. Works as a manager at a local tire and auto company. He has 25 pack/year history of smoking, drinks 2-3 beers/day, and drinks 5-6 cups of coffee per day. He denies illicit drug use, vaping or unprotected sexual encounters. Breath test in the office revealed + urease. The healthcare provider suspects the client has peptic ulcer disease. 1 of 2 Questions: What factors may have contributed to the development of PUD? 2 of 2 Questions:How do these factors contribute to the formation of peptic ulcers? QUESTION 3 A 36-year-old morbidly obese female comes to the office with a chief complaint of “burning in my chest and a funny taste in my mouth”. The symptoms have been present for years but patient states she had been treating the symptoms with antacid tablets which helped until the last 4 or 5 weeks. She never saw a healthcare provider for that. She says the symptoms get worse at night when she is lying down and has had to sleep with 2 pillows. Says she has started coughing at night which has been interfering with her sleep. Also, denies palpitations, shortness of breath, or nausea. PMH-HTN, venous stasis ulcers, irritable bowel syndrome, osteoarthritis of knees, morbid obesity (BMI 48 kg/m2) Family history-non contributary Medications-amlodipine 10 mg po qd, dicyclomine 20 mg po, ibuprofen 600 mg po q 6 hr prn Social hx- 15 pack/year history of smoking, occasional alcohol use, denies vaping The health care provider diagnoses the patient with gastroesophageal reflux disease (GERD). Question: The client asks the APRN what causes GERD. What is the APRN’s best response? QUESTION 4 A 34-year-old construction worker presents to his Primary Care Provider (PCP) with a chief complaint of passing foul smelling dark, tarry stools. He stated the first episode occurred last week, but it was only a small amount after he had eaten a dinner of beets and beef. The episode today was accompanied by nausea, sweating, and weakness. He states he has had some mid epigastric pain for several weeks and has been taking OTC antacids. The most likely diagnosis is upper GI bleed which won’t be confirmed until further endoscopic procedures are performed. Question: What factors can contribute to an upper GI bleed? Question 5 A 64-year-old steel worker presents to h.

1. 1 A 45-year-old male comes to the clinic with a chief complaint
QUESTION 1 A 45-year-old male comes to the clinic with a
chief complaint of epigastric abdominal pain that has persisted
for 2 weeks. He describes the pain as burning, non-radiating and
is worse after meals. Also, he denies nausea, vomiting, weight
loss or obvious bleeding. Finally, he admits to bloating and
frequent belching.
PMH-+ for osteoarthritis, seasonal allergies with frequent
sinusitis infections.
Meds-Zyrtec 10 mg po daily and takes it year-round, ibuprofen
400-600 mg po prn pain
Family Hx-non contributary
Social history-recently divorced and expressed concern at how
expensive it is to support 2 homes. Works as a manager at a
local tire and auto company. He has 25 pack/year history of
smoking, drinks 2-3 beers/day, and drinks 5-6 cups of coffee
per day. He denies illicit drug use, vaping or unprotected sexual
encounters.
Breath test in the office revealed + urease.
The healthcare provider suspects the client has peptic ulcer
disease.
1 of 2 Questions:
What factors may have contributed to the development of PUD?

2. 2 of 2 Questions:How do these factors contribute to the
formation of peptic ulcers?
QUESTION 3 A 36-year-old morbidly obese female comes to
the office with a chief complaint of “burning in my chest and a
funny taste in my mouth”. The symptoms have been present for
years but patient states she had been treating the symptoms with
antacid tablets which helped until the last 4 or 5 weeks. She
never saw a healthcare provider for that. She says the symptoms
get worse at night when she is lying down and has had to sleep
with 2 pillows. Says she has started coughing at night which has
been interfering with her sleep. Also, denies palpitations,
shortness of breath, or nausea.
PMH-HTN, venous stasis ulcers, irritable bowel syndrome,
osteoarthritis of knees, morbid obesity (BMI 48 kg/m2)
Family history-non contributary
Medications-amlodipine 10 mg po qd, dicyclomine 20 mg po,
ibuprofen 600 mg po q 6 hr prn
Social hx- 15 pack/year history of smoking, occasional alcohol
use, denies vaping
The health care provider diagnoses the patient with
gastroesophageal reflux disease (GERD).
Question:
The client asks the APRN what causes GERD. What is the
APRN’s best response?
QUESTION 4 A 34-year-old construction worker presents to his

3. Primary Care Provider (PCP) with a chief complaint of passing
foul smelling dark, tarry stools. He stated the first episode
occurred last week, but it was only a small amount after he had
eaten a dinner of beets and beef. The episode today was
accompanied by nausea, sweating, and weakness. He states he
has had some mid epigastric pain for several weeks and has
been taking OTC antacids. The most likely diagnosis is upper
GI bleed which won’t be confirmed until further endoscopic
procedures are performed.
Question:
What factors can contribute to an upper GI bleed?
Question 5 A 64-year-old steel worker presents to his Primary
Care Provider (PCP) with a chief complaint of passing bright
red blood when he had a bowel movement that morning. He
stated the first episode occurred last week, but it was only a
small amount after he had eaten a dinner of beets and beef. The
episode today was accompanied by nausea, sweating, and
weakness. He states he has had some left lower quadrant pain
for several weeks but described it as “coming and going”. He
says he has had a fever and abdominal cramps that have
worsened this morning. The likely diagnosis is lower GI bleed
secondary to diverticulitis.
Question:
What can cause diverticulitis in the lower GI tract?
QUESTION 6 A 48-year-old man presents to his
gastroenterologist for increasing abdominal girth and increasing

4. jaundice. He has a long history of alcoholic cirrhosis and has
multiple admissions for encephalopathy and GI bleeding from
esophageal varices. He has been diagnosed with portal
hypertension and tells the APRN that he was told he had
chronic, non-curable cirrhosis.
Question:
How does cirrhosis cause portal hypertension?
QUESTION 7 A 48-year-old man presents to his
gastroenterologist for increasing abdominal girth and increasing
jaundice. He has a long history of alcoholic cirrhosis and has
multiple admissions for encephalopathy and GI bleeding from
esophageal varices. He has been diagnosed with portal
hypertension. The increased abdominal girth has been
progressive, and he says it is getting hard to breathe. The APRN
reviews his last laboratory data and notes that the total protein
is 4.6 gm/dl and the albumin is 2.9 g/dl. Upon exam, he has
icteric sclera, jaundice, and abdominal spider angiomas. There
is a significant fluid wave when percussed. The APRN tells the
patient that he has ascites.Question:Discuss how ascites
develops as a result of portal hypertension.
QUESTION 8 A 45-year-old man with known alcoholic
cirrhosis, portal hypertension, and ascites is brought to the ED
by his family due to increasing confusion. The family states that
he had been stumbling for several days but had not fallen. The
family also noted that he had been “flapping his hands” as well.
Labs in the ED reveal Hgb 9.4 g/dl, Hct 28.0 %, ammonia
(NH3) level is 159 μmol/L. The APRN informs the family that
the patient has developed hepatic encephalopathy (HE).

5. Question:
Explain how hepatic encephalopathy develops in patients with
cirrhosis of the liver.
QUESTION 9 A 65-year-old man with a history of atrial
fibrillation presents to his PCP’s office 2 months after suffering
from a myocardial infarction. He declined anticoagulation due
to fear he would bleed to death. Has had sudden-onset,
moderately severe diffuse abdominal pain that began 18 . Has
been vomiting, and he has had several episodes of diarrhea, the
last of which was bloody. He has a fever of 100.9 ˚ F. CBC
reveals WBC of 15,000/mm3.
Question:
What is the most likely mechanism behind his current
symptoms?
QUESTION 10 A 46-year-old Caucasian female presents to the
PCP’s office with a chief complaint of severe, intermittent right
upper quadrant pain for the last 3 days. The pain is described as
sharp and has occurred after eating french fries and
cheeseburgers and radiates to her right shoulder. She has had a
few episodes of vomiting “green stuff”. States had fever and
chills last night which precipitated her trip to the office. She
also had some dark orange urine, but she thought she was
dehydrated.
Physical exam: slightly obese female with icteric sclera as well
as generalized jaundice. Temp 101˚F, pulse 108, respirations

6. 18. Abdominal exam revealed rounded abdomen with slightly
hypoactive bowel sounds. + rebound tenderness on palpation of
right upper quadrant. No tenderness or rebound in epigastrium
or other quadrants. Labs demonstrate elevated WBC, elevated
serum alanine aminotransferase (ALT) and aspartate
aminotransferase (AST) levels. Serum bilirubin (indirect) 2.5
mg/dl. Abdominal ultrasound demonstrated enlarged gall
bladder, dilated common bile duct and multiple stones in the
bile duct. The APRN diagnoses the patient with acute
cholecystitis and refers her to the ED for further treatment.
Question 1 of 2:
Describe how gallstones are formed and why they caused the
symptoms that the patient presented with.
QUESTION 11 A 46-year-old Caucasian female presents to the
PCP’s office with a chief complaint of severe, intermittent right
upper quadrant pain for the last 3 days. The pain is described as
sharp and has occurred after eating french fries and
cheeseburgers and radiates to her right shoulder. She has had a
few episodes of vomiting “green stuff”. States had fever and
chills last night which precipitated her trip to the office. She
also had some dark orange urine, but she thought she was
dehydrated.
Physical exam: slightly obese female with icteric sclera as well
as generalized jaundice. Temp 101˚F, pulse 108, respirations
18. Abdominal exam revealed rounded abdomen with slightly
hypoactive bowel sounds. + rebound tenderness on palpation of
right upper quadrant. No tenderness or rebound in epigastrium
or other quadrants. Labs demonstrate elevated WBC, elevated
serum alanine aminotransferase (ALT) and aspartate
aminotransferase (AST) levels. Serum bilirubin (indirect) 2.5

7. mg/dl. Abdominal ultrasound demonstrated enlarged gall
bladder, dilated common bile duct and multiple stones in the
bile duct. The APRN diagnoses the patient with acute
cholecystitis and refers her to the ED for further treatment.
Question 2 of 2:
Explain how the patient became jaundiced.
QUESTION 12 Ruth is a 49-year-old office worker who
presents to the clinic with a chief complaint of abdominal pain x
2 days. The pain has significantly increased over the past 6
hours and is now accompanied by nausea and vomiting. The
pain is described as “sharp and boring” in mid epigastrum and
radiates to the back. Ruth admits to a long history of alcohol
use, and often drinks up to a fifth of vodka every day.
Physical Exam:
Temp 102.2F, BP 90/60, respirations 22. Pulse Oximetry 92%
on room air.
General: thin, pale white female in obvious pain and leaning
forward. Moving around on exam table and unable to sit quietly.
CV-tachycardic. RRR without gallops, rubs, clicks or murmurs
Resp-decreased breath sounds in both bases with poor
inspiratory effort
Abd- epigastric guarding with tenderness. No rebound
tenderness. Negative Cullen’s and + Turner’s signs observed.
Hypoactive bowel sounds x 2 upper quadrants, and no bowel
sounds heard in both lower quadrants.

8. The APRN makes a tentative diagnosis of acute pancreatitis
based on history and physical exam and has the patient
transferred to the ER where laboratory and radiographic exams
reveal acute pancreatitis.
Question:
Explain how pancreatitis develops and the role alcohol played
in this patient’s case.
QUESTION 13 A 23-year-old bisexual man with a history of
intravenous drug abuse presents to the clinic with a chief
complaint of fever, fatigue, loss of appetite, nausea, vomiting,
abdominal pain, and dark urine. He says the symptoms started
about a month ago and have gotten steadily worse. He admits to
reusing needles and had unprotected sexual relations with a man
“a couple months ago”.
PMH-noncontributory.
Social/family history-works occasionally as a night clerk in a
hotel. Parents without illnesses. Admits to bisexual sexual
relations and intravenous heroin use. He has refused drug
rehabilitation. 3 year/pack history of tobacco but denies vaping.
Physical exam unremarkable except for palpable liver edge 2
fingerbreadths below costal margin. No ascites or jaundice
appreciated.
The APRN suspects the patient has Hepatitis B given the strong
history of risk factors. She orders a hepatitis panel which was
positive for acute Hepatitis B.

9. Question:
What are the important hepatitis markers that indicated the
patient had acute hepatitis B?
QUESTION 14 Hannah is a 19-year-old college sophomore who
came to Student Health with a chief complaint of lower
abdominal pain. She says the pain has been present for 2 months
and she has had multiple episodes of diarrhea alternating with
constipation, and anorexia. She says she has lost about 10
pounds in these 2 months without dieting. The abdominal pain
has gotten worse in the last 2 hours, but she thought she had
“the GI bug” like other students at her Synagogue had.
Physical exam-noncontributory except for the abdomen which
was lightly distended with no visible masses. Normoactive BS x
4. Diffuse tenderness throughout but increased pain on deep
palpation LUQ & LLQ. Slight guarding but no rebound
tenderness or rigidity.
Rectal-tight anal sphincter and patient grimacing in pain during
exam. Slightly + guaiac stool.
Based on her history and current symptoms, the APN arranges
for a consult with a gastroenterologist who diagnoses Hannah
with ulcerative colitis (UC).
Question:
How does ulcerative colitis develop in a susceptible person?
QUESTION 15 A 64-year-old woman with long standing

10. coronary artery disease presents to the clinic with lower
extremity swelling, abdominal distension, and shortness of
breath. Patient states she has a 30-pound weight gain in 6 weeks
and is now requiring 3 pillows to sleep.
On physical exam the patient is a well-developed, well-
nourished female exhibiting signs of respiratory distress with
use of accessory muscles. Blood pressure 150/80, pulse 105,
respirations 28 and labored. Body weight 89 kg. HEENT was
unremarkable. Cardiac exam had an S1, S2 and S3 without S4 or
murmur. Respiratory exam was positive for bilateral rales 1/2
up both lung fields. Abdomen was enlarged with a positive fluid
wave. Lower extremities were remarkable for 3+ pitting edema.
Laboratory data was significant for an increase in K+ from 3.4
mmol/l to 6.1 mmol/l in 2 weeks, BUN increased from 18 mg/dl
to 104 mg/dl, and creatinine increased from 0.8 mg/dl to 6.9
mg/dl.
CXR revealed congestive heart failure. The APRN calls the
cardiologist on call who admits the patient to the hospital and
orders a nephrology consult.
She was diagnosed with exacerbation of congestive heart
failure (CHF) and acute kidney injury (AKI).
Question:
What type of acute kidney injury does the patient have and
what factors contributed to this diagnosis?
QUESTION 16 The APRN is giving a pathophysiology lecture
to APRN students on renal blood flow, related hormones, and
glomerular filtration rate.

11. Question: What would be the most important concept of
glomerular filtration rate that the APRN should address?
QUESTION 17 The APRN is giving a pathophysiology lecture
to APRN students on renal blood flow, glomerular filtration
rate, autoregulation, and related hormone factors regulating
renal blood flow
Question:
What would be the most important concept of autoregulation
that the APRN should address?
QUESTION 18 The APRN is giving a pathophysiology lecture
to APRN students on renal blood flow, glomerular filtration
rate, autoregulation, and also related hormone factors regulating
renal blood flow
Question:
What would be the most important concept of hormonal
regulation that the APRN should address?
QUESTION 19 A 28-year-old female comes to the clinic with a
chief complaint of right flank pain, urinary frequency, and foul-
smelling urine. The symptoms have been present for 3 days but
this morning, the patient states she had a fever of 101 F and
thought she should get it checked out. Physical exam
noncontributory with the exception of right costovertebral angle

12. (CVA) tenderness upon percussion. Urine dipstick shows +
blood, + bacteria and + white blood cells. Renal ultrasound
reveals right staghorn renal calculus and the patient was
diagnosed with acute pyelonephritis.
Question:
How does a renal calculi calculus contribute to acute
pyelonephritis?
QUESTION 20 Mr. Kent is a 45-year-old African American
male with a history of Type 2 diabetes, hypertension, and
hyperlipidemia. His renal function has slowly decreased over
the past 4 years and his nephrologist has told him that his GFR
has decreased to 15cc ml/min and will soon need renal dialysis
for chronic renal failure.
Question:
How does chronic renal failure develop?