CLINICAL CASES • DIFFERENTIAL DIAGNOSIS
NR511
Clinical Cases &
Differential Diagnosis
30 Multi-Step Cases • 150 Clinical Questions
Deep case-based practice progressing through assessment, interpretation, testing, diagnosis, treatment, follow-up,
and escalation decisions across common primary-care presentations.
30 150 5
Clinical Cases Case Questions Decision Points / Case
Original study and revision material • Clean print-ready format PASSPOINT PRO
,PASSPOINT PRO | CHAMBERLAIN NR511 - CEA PRACTICE
Case 1: A 59-year-old woman presents because repeated office blood pressure readings are elevated
without symptoms or an obvious secondary cause. The clinician must identify the likely diagnosis,
choose focused testing, begin treatment, and decide whether any finding requires urgent escalation.
1. A 72-year-old man presents to primary care because repeated office blood pressure readings are elevated
without symptoms or an obvious secondary cause. Which diagnosis is most likely?
A. Atrial fibrillation
B. Stable angina
C. Heart failure
D. Primary hypertension
Answer: D
Explanation: Primary hypertension is the best answer because the key pattern is persistently elevated blood pressure on properly
performed measurements. The competing diagnoses are less consistent with the timing, examination pattern, or risk profile described
in the vignette. Primary care reasoning should also check for urgent features such as hypertensive emergency with acute
target-organ injury before finalizing an outpatient plan.
2. A 67-year-old man presents to primary care because repeated office blood pressure readings are elevated
without symptoms or an obvious secondary cause. Which diagnostic approach is most appropriate next?
A. Use advanced imaging as the first test in every patient regardless of risk
B. confirm with repeat standardized measurements or out-of-office blood pressure monitoring
C. Repeat the same physical examination in several months without additional evaluation
D. Order a broad panel of tests without first estimating pretest probability
Answer: B
Explanation: The most appropriate next diagnostic step is to confirm with repeat standardized measurements or out-of-office blood
pressure monitoring. This approach matches the expected pretest probability and avoids unnecessary testing that would not change
immediate management. If the patient develops hypertensive emergency with acute target-organ injury, the evaluation should be
escalated rather than continuing a routine outpatient workup.
3. A 76-year-old woman presents to primary care because repeated office blood pressure readings are
elevated without symptoms or an obvious secondary cause. What is the best initial management plan?
A. Provide reassurance only and arrange no follow-up
B. Delay treatment until every possible diagnosis has been excluded
C. Start multiple medications before establishing the working diagnosis
D. begin lifestyle modification and initiate guideline-directed antihypertensive therapy when treatment thresholds are met
Answer: D
Explanation: The preferred management approach is to begin lifestyle modification and initiate guideline-directed antihypertensive
therapy when treatment thresholds are met. This plan targets the likely condition while still allowing reassessment if the response is
not as expected. Features such as hypertensive emergency with acute target-organ injury would require urgent escalation or a
different level of care.
4. A patient is being evaluated for Primary hypertension. Which finding should prompt the most urgent
escalation of care?
A. A chronic pattern unchanged for several years
B. Symptoms that are mild, stable, and improving as expected
C. A normal appetite with no systemic symptoms
D. hypertensive emergency with acute target-organ injury
Answer: D
Explanation: The concerning finding is hypertensive emergency with acute target-organ injury. That feature can signal a
time-sensitive complication or an alternative diagnosis that should not be managed as routine follow-up. By contrast, the other
choices describe stable or expected findings that generally allow continued outpatient evaluation when the rest of the examination is
reassuring.
Page 1
,PASSPOINT PRO | CHAMBERLAIN NR511 - CEA PRACTICE
5. Which finding would make Primary hypertension less likely and should cause the clinician to reconsider the
working diagnosis?
A. a single elevated reading caused by pain or anxiety
B. Confirm with repeat standardized measurements or out-of-office blood pressure monitoring
C. Begin lifestyle modification and initiate guideline-directed antihypertensive therapy when treatment thresholds are met
D. persistently elevated blood pressure on properly performed measurements
Answer: A
Explanation: The finding that most argues against Primary hypertension is a single elevated reading caused by pain or anxiety. That
pattern points toward a different diagnostic pathway than the hallmark feature of persistently elevated blood pressure on properly
performed measurements. When findings conflict, the clinician should revisit the differential and use targeted testing rather than
forcing the presentation into the initial diagnosis.
Case 2: A 31-year-old woman presents because substernal pressure occurs with exertion and resolves
within minutes of rest. The clinician must identify the likely diagnosis, choose focused testing, begin
treatment, and decide whether any finding requires urgent escalation.
6. During an outpatient visit, a 76-year-old woman reports that substernal pressure occurs with exertion and
resolves within minutes of rest. Which diagnosis is most likely?
A. Stable angina
B. Heart failure
C. Atrial fibrillation
D. Primary hypertension
Answer: A
Explanation: Stable angina is the best answer because the key pattern is predictable exertional chest discomfort relieved by rest.
The competing diagnoses are less consistent with the timing, examination pattern, or risk profile described in the vignette. Primary
care reasoning should also check for urgent features such as chest pain at rest, dynamic ECG changes, or hemodynamic instability
suggesting acute coronary syndrome before finalizing an outpatient plan.
7. During an outpatient visit, a 59-year-old man reports that substernal pressure occurs with exertion and
resolves within minutes of rest. Which diagnostic approach is most appropriate next?
A. Order a broad panel of tests without first estimating pretest probability
B. Use advanced imaging as the first test in every patient regardless of risk
C. obtain resting ECG and assess ischemic risk; use noninvasive ischemia testing when indicated
D. Repeat the same physical examination in several months without additional evaluation
Answer: C
Explanation: The most appropriate next diagnostic step is to obtain resting ECG and assess ischemic risk; use noninvasive ischemia
testing when indicated. This approach matches the expected pretest probability and avoids unnecessary testing that would not
change immediate management. If the patient develops chest pain at rest, dynamic ECG changes, or hemodynamic instability
suggesting acute coronary syndrome, the evaluation should be escalated rather than continuing a routine outpatient workup.
8. At a same-day clinic visit, a 59-year-old woman explains that substernal pressure occurs with exertion and
resolves within minutes of rest. What is the best initial management plan?
A. Provide reassurance only and arrange no follow-up
B. address cardiovascular risk factors and use antianginal therapy while evaluating for coronary disease
C. Delay treatment until every possible diagnosis has been excluded
D. Start multiple medications before establishing the working diagnosis
Answer: B
Explanation: The preferred management approach is to address cardiovascular risk factors and use antianginal therapy while
evaluating for coronary disease. This plan targets the likely condition while still allowing reassessment if the response is not as
expected. Features such as chest pain at rest, dynamic ECG changes, or hemodynamic instability suggesting acute coronary
syndrome would require urgent escalation or a different level of care.
Page 2
, PASSPOINT PRO | CHAMBERLAIN NR511 - CEA PRACTICE
9. A patient is being evaluated for Stable angina. Which finding should prompt the most urgent escalation of
care?
A. A normal appetite with no systemic symptoms
B. A chronic pattern unchanged for several years
C. chest pain at rest, dynamic ECG changes, or hemodynamic instability suggesting acute coronary syndrome
D. Symptoms that are mild, stable, and improving as expected
Answer: C
Explanation: The concerning finding is chest pain at rest, dynamic ECG changes, or hemodynamic instability suggesting acute
coronary syndrome. That feature can signal a time-sensitive complication or an alternative diagnosis that should not be managed as
routine follow-up. By contrast, the other choices describe stable or expected findings that generally allow continued outpatient
evaluation when the rest of the examination is reassuring.
10. Which finding would make Stable angina less likely and should cause the clinician to reconsider the
working diagnosis?
A. pleuritic pain that varies with breathing or reproducible chest wall tenderness
B. Obtain resting ecg and assess ischemic risk; use noninvasive ischemia testing when indicated
C. predictable exertional chest discomfort relieved by rest
D. Address cardiovascular risk factors and use antianginal therapy while evaluating for coronary disease
Answer: A
Explanation: The finding that most argues against Stable angina is pleuritic pain that varies with breathing or reproducible chest wall
tenderness. That pattern points toward a different diagnostic pathway than the hallmark feature of predictable exertional chest
discomfort relieved by rest. When findings conflict, the clinician should revisit the differential and use targeted testing rather than
forcing the presentation into the initial diagnosis.
Case 3: A 72-year-old man presents because progressive dyspnea, orthopnea, and bilateral ankle
edema are present. The clinician must identify the likely diagnosis, choose focused testing, begin
treatment, and decide whether any finding requires urgent escalation.
11. A 76-year-old man presents to primary care because progressive dyspnea, orthopnea, and bilateral ankle
edema are present. Which diagnosis is most likely?
A. Primary hypertension
B. Atrial fibrillation
C. Heart failure
D. Stable angina
Answer: C
Explanation: Heart failure is the best answer because the key pattern is volume-overload symptoms with exertional dyspnea and
orthopnea. The competing diagnoses are less consistent with the timing, examination pattern, or risk profile described in the vignette.
Primary care reasoning should also check for urgent features such as acute pulmonary edema, hypoxia, shock, or severe respiratory
distress before finalizing an outpatient plan.
12. A 42-year-old woman seeks evaluation after noticing that progressive dyspnea, orthopnea, and bilateral
ankle edema are present. Which diagnostic approach is most appropriate next?
A. Order a broad panel of tests without first estimating pretest probability
B. Use advanced imaging as the first test in every patient regardless of risk
C. obtain ECG, chest imaging, natriuretic peptide when appropriate, and echocardiography to assess structure and ejection
fraction
D. Repeat the same physical examination in several months without additional evaluation
Answer: C
Explanation: The most appropriate next diagnostic step is to obtain ECG, chest imaging, natriuretic peptide when appropriate, and
echocardiography to assess structure and ejection fraction. This approach matches the expected pretest probability and avoids
unnecessary testing that would not change immediate management. If the patient develops acute pulmonary edema, hypoxia, shock,
or severe respiratory distress, the evaluation should be escalated rather than continuing a routine outpatient workup.
Page 3
NR511
Clinical Cases &
Differential Diagnosis
30 Multi-Step Cases • 150 Clinical Questions
Deep case-based practice progressing through assessment, interpretation, testing, diagnosis, treatment, follow-up,
and escalation decisions across common primary-care presentations.
30 150 5
Clinical Cases Case Questions Decision Points / Case
Original study and revision material • Clean print-ready format PASSPOINT PRO
,PASSPOINT PRO | CHAMBERLAIN NR511 - CEA PRACTICE
Case 1: A 59-year-old woman presents because repeated office blood pressure readings are elevated
without symptoms or an obvious secondary cause. The clinician must identify the likely diagnosis,
choose focused testing, begin treatment, and decide whether any finding requires urgent escalation.
1. A 72-year-old man presents to primary care because repeated office blood pressure readings are elevated
without symptoms or an obvious secondary cause. Which diagnosis is most likely?
A. Atrial fibrillation
B. Stable angina
C. Heart failure
D. Primary hypertension
Answer: D
Explanation: Primary hypertension is the best answer because the key pattern is persistently elevated blood pressure on properly
performed measurements. The competing diagnoses are less consistent with the timing, examination pattern, or risk profile described
in the vignette. Primary care reasoning should also check for urgent features such as hypertensive emergency with acute
target-organ injury before finalizing an outpatient plan.
2. A 67-year-old man presents to primary care because repeated office blood pressure readings are elevated
without symptoms or an obvious secondary cause. Which diagnostic approach is most appropriate next?
A. Use advanced imaging as the first test in every patient regardless of risk
B. confirm with repeat standardized measurements or out-of-office blood pressure monitoring
C. Repeat the same physical examination in several months without additional evaluation
D. Order a broad panel of tests without first estimating pretest probability
Answer: B
Explanation: The most appropriate next diagnostic step is to confirm with repeat standardized measurements or out-of-office blood
pressure monitoring. This approach matches the expected pretest probability and avoids unnecessary testing that would not change
immediate management. If the patient develops hypertensive emergency with acute target-organ injury, the evaluation should be
escalated rather than continuing a routine outpatient workup.
3. A 76-year-old woman presents to primary care because repeated office blood pressure readings are
elevated without symptoms or an obvious secondary cause. What is the best initial management plan?
A. Provide reassurance only and arrange no follow-up
B. Delay treatment until every possible diagnosis has been excluded
C. Start multiple medications before establishing the working diagnosis
D. begin lifestyle modification and initiate guideline-directed antihypertensive therapy when treatment thresholds are met
Answer: D
Explanation: The preferred management approach is to begin lifestyle modification and initiate guideline-directed antihypertensive
therapy when treatment thresholds are met. This plan targets the likely condition while still allowing reassessment if the response is
not as expected. Features such as hypertensive emergency with acute target-organ injury would require urgent escalation or a
different level of care.
4. A patient is being evaluated for Primary hypertension. Which finding should prompt the most urgent
escalation of care?
A. A chronic pattern unchanged for several years
B. Symptoms that are mild, stable, and improving as expected
C. A normal appetite with no systemic symptoms
D. hypertensive emergency with acute target-organ injury
Answer: D
Explanation: The concerning finding is hypertensive emergency with acute target-organ injury. That feature can signal a
time-sensitive complication or an alternative diagnosis that should not be managed as routine follow-up. By contrast, the other
choices describe stable or expected findings that generally allow continued outpatient evaluation when the rest of the examination is
reassuring.
Page 1
,PASSPOINT PRO | CHAMBERLAIN NR511 - CEA PRACTICE
5. Which finding would make Primary hypertension less likely and should cause the clinician to reconsider the
working diagnosis?
A. a single elevated reading caused by pain or anxiety
B. Confirm with repeat standardized measurements or out-of-office blood pressure monitoring
C. Begin lifestyle modification and initiate guideline-directed antihypertensive therapy when treatment thresholds are met
D. persistently elevated blood pressure on properly performed measurements
Answer: A
Explanation: The finding that most argues against Primary hypertension is a single elevated reading caused by pain or anxiety. That
pattern points toward a different diagnostic pathway than the hallmark feature of persistently elevated blood pressure on properly
performed measurements. When findings conflict, the clinician should revisit the differential and use targeted testing rather than
forcing the presentation into the initial diagnosis.
Case 2: A 31-year-old woman presents because substernal pressure occurs with exertion and resolves
within minutes of rest. The clinician must identify the likely diagnosis, choose focused testing, begin
treatment, and decide whether any finding requires urgent escalation.
6. During an outpatient visit, a 76-year-old woman reports that substernal pressure occurs with exertion and
resolves within minutes of rest. Which diagnosis is most likely?
A. Stable angina
B. Heart failure
C. Atrial fibrillation
D. Primary hypertension
Answer: A
Explanation: Stable angina is the best answer because the key pattern is predictable exertional chest discomfort relieved by rest.
The competing diagnoses are less consistent with the timing, examination pattern, or risk profile described in the vignette. Primary
care reasoning should also check for urgent features such as chest pain at rest, dynamic ECG changes, or hemodynamic instability
suggesting acute coronary syndrome before finalizing an outpatient plan.
7. During an outpatient visit, a 59-year-old man reports that substernal pressure occurs with exertion and
resolves within minutes of rest. Which diagnostic approach is most appropriate next?
A. Order a broad panel of tests without first estimating pretest probability
B. Use advanced imaging as the first test in every patient regardless of risk
C. obtain resting ECG and assess ischemic risk; use noninvasive ischemia testing when indicated
D. Repeat the same physical examination in several months without additional evaluation
Answer: C
Explanation: The most appropriate next diagnostic step is to obtain resting ECG and assess ischemic risk; use noninvasive ischemia
testing when indicated. This approach matches the expected pretest probability and avoids unnecessary testing that would not
change immediate management. If the patient develops chest pain at rest, dynamic ECG changes, or hemodynamic instability
suggesting acute coronary syndrome, the evaluation should be escalated rather than continuing a routine outpatient workup.
8. At a same-day clinic visit, a 59-year-old woman explains that substernal pressure occurs with exertion and
resolves within minutes of rest. What is the best initial management plan?
A. Provide reassurance only and arrange no follow-up
B. address cardiovascular risk factors and use antianginal therapy while evaluating for coronary disease
C. Delay treatment until every possible diagnosis has been excluded
D. Start multiple medications before establishing the working diagnosis
Answer: B
Explanation: The preferred management approach is to address cardiovascular risk factors and use antianginal therapy while
evaluating for coronary disease. This plan targets the likely condition while still allowing reassessment if the response is not as
expected. Features such as chest pain at rest, dynamic ECG changes, or hemodynamic instability suggesting acute coronary
syndrome would require urgent escalation or a different level of care.
Page 2
, PASSPOINT PRO | CHAMBERLAIN NR511 - CEA PRACTICE
9. A patient is being evaluated for Stable angina. Which finding should prompt the most urgent escalation of
care?
A. A normal appetite with no systemic symptoms
B. A chronic pattern unchanged for several years
C. chest pain at rest, dynamic ECG changes, or hemodynamic instability suggesting acute coronary syndrome
D. Symptoms that are mild, stable, and improving as expected
Answer: C
Explanation: The concerning finding is chest pain at rest, dynamic ECG changes, or hemodynamic instability suggesting acute
coronary syndrome. That feature can signal a time-sensitive complication or an alternative diagnosis that should not be managed as
routine follow-up. By contrast, the other choices describe stable or expected findings that generally allow continued outpatient
evaluation when the rest of the examination is reassuring.
10. Which finding would make Stable angina less likely and should cause the clinician to reconsider the
working diagnosis?
A. pleuritic pain that varies with breathing or reproducible chest wall tenderness
B. Obtain resting ecg and assess ischemic risk; use noninvasive ischemia testing when indicated
C. predictable exertional chest discomfort relieved by rest
D. Address cardiovascular risk factors and use antianginal therapy while evaluating for coronary disease
Answer: A
Explanation: The finding that most argues against Stable angina is pleuritic pain that varies with breathing or reproducible chest wall
tenderness. That pattern points toward a different diagnostic pathway than the hallmark feature of predictable exertional chest
discomfort relieved by rest. When findings conflict, the clinician should revisit the differential and use targeted testing rather than
forcing the presentation into the initial diagnosis.
Case 3: A 72-year-old man presents because progressive dyspnea, orthopnea, and bilateral ankle
edema are present. The clinician must identify the likely diagnosis, choose focused testing, begin
treatment, and decide whether any finding requires urgent escalation.
11. A 76-year-old man presents to primary care because progressive dyspnea, orthopnea, and bilateral ankle
edema are present. Which diagnosis is most likely?
A. Primary hypertension
B. Atrial fibrillation
C. Heart failure
D. Stable angina
Answer: C
Explanation: Heart failure is the best answer because the key pattern is volume-overload symptoms with exertional dyspnea and
orthopnea. The competing diagnoses are less consistent with the timing, examination pattern, or risk profile described in the vignette.
Primary care reasoning should also check for urgent features such as acute pulmonary edema, hypoxia, shock, or severe respiratory
distress before finalizing an outpatient plan.
12. A 42-year-old woman seeks evaluation after noticing that progressive dyspnea, orthopnea, and bilateral
ankle edema are present. Which diagnostic approach is most appropriate next?
A. Order a broad panel of tests without first estimating pretest probability
B. Use advanced imaging as the first test in every patient regardless of risk
C. obtain ECG, chest imaging, natriuretic peptide when appropriate, and echocardiography to assess structure and ejection
fraction
D. Repeat the same physical examination in several months without additional evaluation
Answer: C
Explanation: The most appropriate next diagnostic step is to obtain ECG, chest imaging, natriuretic peptide when appropriate, and
echocardiography to assess structure and ejection fraction. This approach matches the expected pretest probability and avoids
unnecessary testing that would not change immediate management. If the patient develops acute pulmonary edema, hypoxia, shock,
or severe respiratory distress, the evaluation should be escalated rather than continuing a routine outpatient workup.
Page 3
