Differential

Diagnoses
-coming up with 1 or 2 (focusing on the most common and most dangerous) for
each of the following organ systems will help you expand the your differential. I try
and think of the organs/structures surrounding the patient’s area of pain and then
thinking of diagnoses specific to that area/organ helps me build a differential.
****information gathered from UTD and Harrison’s Internal Medicine

1) Chest Pain
CARDIAC RESPIRATORY
Myocardial ischemia (MI/angina) Pulmonary Embolism
Aortic dissection Pneumothorax
Pericarditis/myocarditis Pneumonia
Acute decompensated HF Cancer
Mitral Stenosis/Prolapse Pleuritis
Aortic Stenosis Sarcoidosis
Tachyarrhythmia Acute Chest Syndrome/Sickle Cell Anemia
GASTROINTESTINAL Pulmonary Hypertension
Esophageal perforation MUSCULOSKELETAL
GERD Costochondritis
Esophagitis Muscle Strain
Hiatal Hernia Rib/Sternal Fracture
Esophageal Spasm Rheumatic Diseases
SKIN PSYCHIATRIC
Herpes Zoster Panic Attack/Anxiety
Depression
Somatization

2) Dyspnea
UPPER AIRWAY PULMONARY
Foreign body obstruction Pulmonary Embolism
Angioedema COPD
Anaphylaxis Asthma
Infection (epiglottitis, diptheria, etc) Pneumothorax
Trauma Infection (Pneumonia, abscess)
CARDIAC ARDS
MI Trauma
Acute Heart Failure Pulmonary Hemorrhage (ex. Wegner’s)
Cardiomyopathy Interstitial Lung Disease
Arrhythmia NEUROLOGIC
Valve Dysfunction Stroke (aspiration, diaphragm paralysis)
Cardiac Tamponade Neuromuscular Disease
TOXIC METABOLIC
Poisioning DKA
Aspirin Overdose
Carbon Monoxide

OTHER
Sepsis
Acute Chest Syndrome (Sickle Cell Crisis)
Cancer
Intraabdominal Processes

Physiological Basis of CVS Exam

1) In a 38 year old female diagnosed with severe pulmonary hypertension
secondary to frequent pulmonary emboli. On examination, the JVP demonstrates a
very prominent “a” wave. Please explain the physiological explanation for this
finding. This finding is caused by which of the following?
1. Short diastolic filling period
2. Increased LV preload
3. Decreased right ventricular compliance – remember that pulm HTN is an
afterload problem and over time causes thickening of the right ventricle and
hypertrophy. This results in a stiff (non-compliant) ventricle that will not
expand very well when the right atria contracts. This results is and increased
height in the a wave as more blood enters the SVC and internal jugular vein
because it can’t all go into the right ventricle.
4. Increased right ventricular compliance

2) A 45-year-old man has severe aortic stenosis. On palpation it is noted that
carotid pulse rises very slowly. The mechanism is
1. Low cardiac output
2. Shortened diastole
3. Decreased flow velocity- the stenotic valve restricts the flow of blood
through the valve resulting in a delayed and slow pulse (pulsus parvus et
tardus)
4. Increased peripheral vascular resistance
5. Decreased compliance

3) A 50 yo male with long standing dilated cardiomyopathy will likely have all of the
findings below on palpation of the chest, except which of the following?
1. Decreased duration– remember the changes to the apical impulse with HF
include lateral displacement and increased size (due to
hypertrophy/dilation) and increased duration and decreased amplitude due
to poor contractility.
2. Increased size
3. Decreased Amplitude
4. Lateral displacement

4) A 45-year-old man is admitted in shock (BP 65/45 mmHg), heart rate 135 bpm).
The first heart sound should be
1. Split
2. Paradoxical
 3. Increased – shock will cause increase in HR and contractility as a result of
compensatory mechanisms (sympathetic stimulation)
4. Decreased – due to decreased contractility

5) A 62-year-old woman with severe systemic hypertension who has showed a loud
S4 now develops atrial fibrillation. Which of the following will be true?
1. S4 will be softer
2. S4 will be closer to S1
3. S4 will not be audible – remember S4 is from blood flow due to atrial
contraction hitting a stiff, thick ventricular wall at the end of diastole
4. S4 will be louder

6) A 80-year-old man with severe calcified aortic stenosis will not have an ejection
sound because ejection sounds depend on
1. Duration of systole
2. Preload
3. Afterload
4. Leaflet motion - In patients with valvular aortic stenosis ejection click depends on
the mobility of the leaflets; calcified leaflets lose their mobility and the ejection click
will not be present


7) 30-year-old male presents to his physician c/o constant, sharp, non-radiating,
6/10 substernal chest pain for 3 days. Not aggravated by exertion, but worse with
coughing and relieved with leaning forward. Physical exam is normal except for
continuous, rough heart sounds. What abnormality may be seen on ECG?
1. Prolonged QTc
2. Progressively prolonged PR interval, then dropped beat
3. Diffuse ST-segment elevation case presentation of acute pericarditis (diffuse
ST-segment elevation vs MI with localization of the occlusion/infarct)
4. Peaked T waves
5. ST-segment elevation in leads II, III, and aVF

Valvular Heart Disease

1) A 35 year-old male comes to a family doctor looking to establish a new primary
care physician. The patient’s history is significant for a mutation in the fibrillin gene.
His doctor pays special attention to the cardiac auscultation, where he hears a
diastolic murmur along the left sternal border. This would cause which of the
following changes?
1. Left atrial enlargement
2. Increased right ventricular pressure
3. Left ventricular systolic pressure higher than aortic pressure
4. Elevated left atrial end diastolic volume
 5. Elevated left ventricular end diastolic volume - case of aortic regurgitation
which is a volume problem and causes dilation!! And results in elevated LV
EDV

2) A 36-year-old woman presents complaining of episodic light-headedness and
occasional fainting spells. Mild dysphagia and hoarseness is noted, which she
complains is a recent development within the past month. She has no other
complaints, her lab values are normal, but on physical exam a diastolic heart
murmur that is more pronounced at the apex is noted. Which of the following heart
valves is most likely affected?
1. Mitral – mitral stenosis (diastolic murmur) causing LAE, remember from
anatomy the LA sits directly in front of the esophagus and the recurrent
laryngeal nerve
2. Pulmonic
3. Aoritc
4. Tricuspid

3) 18 year-old male presents to his physician for a high school sports physical. He is
noted to to 6’5” and thin with long arms and fingers. Which of the following physical
exam findings is consistent with a diagnosis of mitral regurgitation?
1. Crescendo-decrescendo systolic murmur
2. Mid-systolic click
3. Delayed and weak carotid pulse
4. Holosystolic murmur – remember wide pressure gradient means the
murmur is heard immediately and covers up the S1 and lasts to the end of
systole covering up S2
5. Widened pulse pressure

4) A 64-year-old female who recently moved comes to the doctor’s office as a new
patient. As part of the initial physical exam, her doctor notices an abnormal systolic
sound during cardiac auscultation. When he asks if anyone has ever told the patient
that she has a heart murmur, she says someone mentioned it once, but she has never
been worked up for it. No other cardiac abnormalities are noted. This is consistent
with which of the following murmurs?
1. Aortic Stenosis
2. Aortic Regurgitation
3. Mitral Valve Prolapse – typical case presentation of MVP, abnormal systolic
(click) with potential for late systolic murmur (MR) and very often no other
cardiac issues
4. Mitral Stenosis
5. Mitral Regurgitation

Congenital Heart Disease

1) Which of the following is least likely to cause sudden cardiac death?
1. Long QT Syndrome
 2. Hypertrophic Obstructive Cardiomyopathy
3. Wolf-Parkinson White
4. Severe Aortic Stenosis
5. Chronic Mitral Regurgitation – acute mitral regurgitaiton can cause acute
elevation in LA pressure (as there is not time for the LA to expand) and
pulmonary edema/death (not sudden death – ie arrhythmia)

2) Which of the following does not contribute to the closure of fetal circulatory
bypass systems after birth?
1. Decreased umbilical vein flow
2. Decreased prostaglandins
3. Decreased total peripheral resistance – with increased blood flow through
the lungs and into the LA/V you get increased contractility and elevated
systemic blood pressure. Flow of blood from the pulmonary vein into the
aorta reverses until the closure of the ductus arteriosus is complete (usually
w/in hours of life)
4. Decreased right atrial pressure
5. Decreased pulmonary vascular resistance

3) The architectural layout of the majority of the heart and its chambers is formed
by the eighth week of development. However, septation of the atria is not completed
until birth. Several structures are involved in the septation process. During this
process, which of the following structures is formed as a direct result of apoptosis?
1. Foramen ovale
2. Foramen primum
3. Foramen secundum – the second hole (foramen) formed via apoptosis in the
septum primum (cranially) – review the embryology
4. Septum primum
5. Septum secundum

4) Which of the following findings is not common to coarctation of the aorta?
1. S4
2. Radial/femoral delay
3. Decreased blood pressure in the right arm – increased upper extremity and
decreased lower extremity BP due to constriction in the post ductal aorta
4. ECG with left axis deviation
5. Chest x-ray with inferior rib notching and hyperlucency

5) 5 year-old girl is brought to the pediatrician after her teacher noticed she has
been turning blue while running or crying. The child crouches down and then
seems fine. Which of the following echocardiogram findings are consistent with this
diagnosis?
1. Left-to-right shunt
2. Right atrial enlargement
 3. Overriding aorta – classic Tetralogy scenario with the 4 main anatomical
abnormalities being pulmonic stenosis, overriding aorta, VSD and concentric
RVH
4. Patent foramen ovale
5. Aortic valve stenosis

6) 8 year-old female born if Africa is brought to the US for cardiac surgery. She is
small for her age and has had a good activity level, but has recently become cyanotic.
Echocardiogram revealed a large ventral septal defect. What is the cause of the
patients cyanosis?
1. Left-to-right interatrial shunt
2. Left-to-right interventricular shunt
3. Patent ductus arteriosus
4. Transposition of the great vessels
5. Pulmonary hypertension over time, chronic left-to-right shunt increased
pulmonary vascular blood flow and eventual increases pulmonary vascular
resistance which results in pulmonary hypertension and reversal of the
shunt to right-to-left with deoxygenated blood going into the LV
(Eisenmenger Syndrome)