NR 511
Differential Diagnosis & Primary Care Practicum
Final Exam Questions with Answers
Chamberlain
,Question 1
A 58-year-old man reports substernal chest pressure that began while
shoveling snow, radiates to his left jaw, and is accompanied by diaphoresis
and nausea. It resolves within 10 minutes of rest. Which diagnosis is most
likely?
A. Stable angina
B. GERD
C. Costochondritis
D. Panic attack
Correct Answer: A. Stable angina
Rationale:
Exertional substernal pressure that radiates to the jaw/arm, is accompanied
by autonomic symptoms (diaphoresis, nausea), and resolves promptly with
rest is the classic pattern of stable angina from demand ischemia in fixed
coronary stenosis. GERD typically causes burning pain related to
meals/recumbency and responds to antacids rather than rest.
Costochondritis produces reproducible pain on palpation of the costosternal
joints, unrelated to exertion. A panic attack can mimic cardiac chest pain but
usually has an acute onset with hyperventilation, paresthesias, and a sense
of impending doom rather than a clear exertional trigger with reproducible
relief by rest. The exertional trigger and prompt resolution with rest are the
key differentiating features pointing to angina, and this presentation warrants
urgent cardiac risk stratification (ECG, troponin, stress testing) regardless of
the eventual diagnosis.
Question 2
A 45-year-old woman presents with sharp, stabbing left-sided chest pain that
worsens with deep inspiration and improves when she leans forward. She
had an upper respiratory infection last week. Which is the most likely
diagnosis?
, A. Acute pericarditis
B. Acute myocardial infarction
C. Pulmonary embolism
D. Stable angina
Correct Answer: A. Acute pericarditis
Rationale:
Pleuritic chest pain that is relieved by leaning forward (decreasing pressure
on the inflamed pericardium against the chest wall) following a recent viral
illness is classic for acute pericarditis, often viral in etiology. MI pain is
typically pressure-like, not sharp/positional, and not pleuritic. PE can cause
pleuritic pain but usually presents with dyspnea, tachycardia, and risk factors
for VTE (immobility, malignancy, recent surgery) rather than a
positional/postural component and antecedent viral prodrome. Stable angina
is exertional and pressure-like, not positional or pleuritic. The positional
nature of the pain plus the recent viral prodrome are the distinguishing clues
for pericarditis; an ECG showing diffuse ST elevation with PR depression
would support this diagnosis.
Question 3
A 62-year-old man with a history of hypertension presents with sudden,
tearing chest pain radiating to his back, and his blood pressure is 168/60
mmHg in the right arm and 128/58 mmHg in the left arm. What is the most
likely diagnosis?
A. Aortic dissection
B. Acute pericarditis
C. Musculoskeletal chest pain
D. Esophageal spasm
Correct Answer: A. Aortic dissection
Rationale:
Sudden, tearing/ripping chest pain radiating to the back with a blood pressure
discrepancy between arms (greater than 20 mmHg) is a hallmark
presentation of aortic dissection. This is a surgical emergency requiring
, immediate imaging (CT angiography) rather than routine outpatient workup.
Pericarditis causes pleuritic, positional pain without a blood pressure
differential. Musculoskeletal pain is reproducible with palpation and not
associated with hemodynamic asymmetry. Esophageal spasm can mimic
cardiac pain but does not cause interarm blood pressure discrepancies or
radiation to the back with a tearing quality. Recognizing the interarm BP
differential and tearing quality is critical because misdiagnosing dissection as
ACS and giving anticoagulants/thrombolytics can be catastrophic.
Question 4
A 30-year-old woman with no cardiac risk factors reports chest pain that is
reproducible with palpation of the costosternal junctions bilaterally. There is
no radiation, dyspnea, or diaphoresis. What is the most likely diagnosis?
A. Costochondritis
B. Unstable angina
C. Pulmonary embolism
D. Aortic dissection
Correct Answer: A. Costochondritis
Rationale:
Reproducible chest wall tenderness on palpation, without radiation, dyspnea,
or autonomic symptoms, in a low-risk patient strongly suggests a
musculoskeletal cause such as costochondritis. True cardiac ischemic pain is
typically not reproducible by palpation. Unstable angina presents with pain at
rest or with minimal exertion, often with diaphoresis, and is not reproducible
by chest wall palpation. PE presents with pleuritic pain, dyspnea, and
tachycardia, plus VTE risk factors. Aortic dissection presents with sudden
tearing pain and hemodynamic instability. Reproducibility of pain with direct
palpation is one of the most useful bedside findings to lower the probability of
an acute coronary or vascular cause, though a full risk assessment (HEART
score, ECG) should still be considered if any risk factors exist.
Question 5
Differential Diagnosis & Primary Care Practicum
Final Exam Questions with Answers
Chamberlain
,Question 1
A 58-year-old man reports substernal chest pressure that began while
shoveling snow, radiates to his left jaw, and is accompanied by diaphoresis
and nausea. It resolves within 10 minutes of rest. Which diagnosis is most
likely?
A. Stable angina
B. GERD
C. Costochondritis
D. Panic attack
Correct Answer: A. Stable angina
Rationale:
Exertional substernal pressure that radiates to the jaw/arm, is accompanied
by autonomic symptoms (diaphoresis, nausea), and resolves promptly with
rest is the classic pattern of stable angina from demand ischemia in fixed
coronary stenosis. GERD typically causes burning pain related to
meals/recumbency and responds to antacids rather than rest.
Costochondritis produces reproducible pain on palpation of the costosternal
joints, unrelated to exertion. A panic attack can mimic cardiac chest pain but
usually has an acute onset with hyperventilation, paresthesias, and a sense
of impending doom rather than a clear exertional trigger with reproducible
relief by rest. The exertional trigger and prompt resolution with rest are the
key differentiating features pointing to angina, and this presentation warrants
urgent cardiac risk stratification (ECG, troponin, stress testing) regardless of
the eventual diagnosis.
Question 2
A 45-year-old woman presents with sharp, stabbing left-sided chest pain that
worsens with deep inspiration and improves when she leans forward. She
had an upper respiratory infection last week. Which is the most likely
diagnosis?
, A. Acute pericarditis
B. Acute myocardial infarction
C. Pulmonary embolism
D. Stable angina
Correct Answer: A. Acute pericarditis
Rationale:
Pleuritic chest pain that is relieved by leaning forward (decreasing pressure
on the inflamed pericardium against the chest wall) following a recent viral
illness is classic for acute pericarditis, often viral in etiology. MI pain is
typically pressure-like, not sharp/positional, and not pleuritic. PE can cause
pleuritic pain but usually presents with dyspnea, tachycardia, and risk factors
for VTE (immobility, malignancy, recent surgery) rather than a
positional/postural component and antecedent viral prodrome. Stable angina
is exertional and pressure-like, not positional or pleuritic. The positional
nature of the pain plus the recent viral prodrome are the distinguishing clues
for pericarditis; an ECG showing diffuse ST elevation with PR depression
would support this diagnosis.
Question 3
A 62-year-old man with a history of hypertension presents with sudden,
tearing chest pain radiating to his back, and his blood pressure is 168/60
mmHg in the right arm and 128/58 mmHg in the left arm. What is the most
likely diagnosis?
A. Aortic dissection
B. Acute pericarditis
C. Musculoskeletal chest pain
D. Esophageal spasm
Correct Answer: A. Aortic dissection
Rationale:
Sudden, tearing/ripping chest pain radiating to the back with a blood pressure
discrepancy between arms (greater than 20 mmHg) is a hallmark
presentation of aortic dissection. This is a surgical emergency requiring
, immediate imaging (CT angiography) rather than routine outpatient workup.
Pericarditis causes pleuritic, positional pain without a blood pressure
differential. Musculoskeletal pain is reproducible with palpation and not
associated with hemodynamic asymmetry. Esophageal spasm can mimic
cardiac pain but does not cause interarm blood pressure discrepancies or
radiation to the back with a tearing quality. Recognizing the interarm BP
differential and tearing quality is critical because misdiagnosing dissection as
ACS and giving anticoagulants/thrombolytics can be catastrophic.
Question 4
A 30-year-old woman with no cardiac risk factors reports chest pain that is
reproducible with palpation of the costosternal junctions bilaterally. There is
no radiation, dyspnea, or diaphoresis. What is the most likely diagnosis?
A. Costochondritis
B. Unstable angina
C. Pulmonary embolism
D. Aortic dissection
Correct Answer: A. Costochondritis
Rationale:
Reproducible chest wall tenderness on palpation, without radiation, dyspnea,
or autonomic symptoms, in a low-risk patient strongly suggests a
musculoskeletal cause such as costochondritis. True cardiac ischemic pain is
typically not reproducible by palpation. Unstable angina presents with pain at
rest or with minimal exertion, often with diaphoresis, and is not reproducible
by chest wall palpation. PE presents with pleuritic pain, dyspnea, and
tachycardia, plus VTE risk factors. Aortic dissection presents with sudden
tearing pain and hemodynamic instability. Reproducibility of pain with direct
palpation is one of the most useful bedside findings to lower the probability of
an acute coronary or vascular cause, though a full risk assessment (HEART
score, ECG) should still be considered if any risk factors exist.
Question 5
