Chest pain in primary care is a rule-out before it is a diagnosis. These questions cover the features that distinguish cardiac from musculoskeletal, gastrointestinal and anxiety-related pain, risk stratification, the ECG changes that demand immediate transfer rather than an outpatient work-up, and how to handle the atypical presentations common in women and people with diabetes. All 10 questions are pitched at Family Nurse Practitioner (FNP-BC / FNP-C) board level, each with a full rationale.
Question 1
A 55-year-old male requests treatment for erectile dysfunction. His medical history includes hypertension and stable angina. His current medications include amlodipine, aspirin, and isosorbide mononitrate. Which action is most appropriate?
- A) Prescribe sildenafil with instructions to hold the daily nitrate dose.
- B) Prescribe tadalafil daily to minimize sudden drops in blood pressure.
- C) Withhold PDE5 inhibitors due to the risk of severe hypotension.✓
- D) Withhold PDE5 inhibitors and switch amlodipine to a beta blocker.
💡 Key Takeaway
PDE5 inhibitors are absolutely contraindicated in patients taking any form of nitrate therapy.
Show rationale
The use of PDE5 inhibitors is absolutely contraindicated in patients taking scheduled or as-needed nitrates, like isosorbide mononitrate, due to the risk of profound, potentially fatal hypotension. Option C is correct because prescribing these together violates established safety guidelines. Option A is incorrect because holding a daily nitrate does not clear the drug sufficiently to safely use a PDE5 inhibitor, risking a cardiac event. Option B is incorrect because daily tadalafil still interacts dangerously with nitrates. Option D is incorrect because amlodipine is not the contraindicating factor; the nitrate is the primary issue, and switching the antihypertensive does not resolve the absolute contraindication.
Question 2
A 62-year-old male presents for management of erectile dysfunction. His medical history includes stable angina, hypertension, and dyslipidemia. His current daily medications are amlodipine, atorvastatin, and isosorbide mononitrate. He requests a prescription for sildenafil. What is the most appropriate prescribing action?
- A) Prescribe sildenafil but advise separating it from nitrates by twelve hours.
- B) Recommend an intraurethral alprostadil suppository instead of an oral PDE5 inhibitor.✓
- C) Switch his isosorbide mononitrate to a daily transdermal nitroglycerin patch therapy.
- D) Prescribe daily tadalafil because it provides a safer peak concentration profile.
💡 Key Takeaway
PDE5 inhibitors are absolutely contraindicated with any form of nitrate therapy due to severe hypotensive risks.
Show rationale
Nitrates are an absolute contraindication for all PDE5 inhibitors due to the risk of profound, refractory hypotension. Because this patient requires isosorbide mononitrate for stable angina, oral PDE5 inhibitors like sildenafil or tadalafil (Options A and D) cannot be safely prescribed, even if doses are separated by time. Switching to a transdermal nitrate (Option C) does not eliminate this dangerous interaction. Therefore, a localized, non-systemic alternative such as intraurethral alprostadil (Option B) is the safest and most appropriate pharmacological intervention for his erectile dysfunction.
Question 3
A 58-year-old male with a recent myocardial infarction is prescribed branded rosuvastatin 40 mg but reports a high insurance copayment preventing him from filling it. His LDL-C is 135 mg/dL. Which modification provides equivalent cardiovascular protection while minimizing the patient's out-of-pocket costs?
- A) Change to generic pravastatin 40 mg daily
- B) Change to generic simvastatin 20 mg daily
- C) Change to generic lovastatin 40 mg daily
- D) Change to generic atorvastatin 80 mg daily✓
💡 Key Takeaway
Generic atorvastatin 80 mg provides high-intensity lipid lowering equivalent to branded rosuvastatin at a lower cost.
Show rationale
A patient with a recent myocardial infarction requires high-intensity statin therapy for optimal secondary cardiovascular prevention. Generic atorvastatin 80 mg is a high-intensity statin that provides equivalent lipid-lowering efficacy to branded rosuvastatin 40 mg, but at a fraction of the cost, directly addressing his copayment barrier. Pravastatin, simvastatin, and lovastatin are widely available as inexpensive generics; however, they are only capable of providing moderate-intensity lipid lowering at their maximum doses. Prescribing a moderate-intensity statin would inappropriately compromise his cardiovascular protection. Switching within the same therapeutic intensity class to a generic alternative ensures he receives guideline-directed medical therapy without financial hardship.
Question 4
A 15-year-old male presents for a preparticipation sports physical. He denies any chest pain, shortness of breath, or syncope. His family history is unknown because he was adopted. Auscultation reveals a systolic murmur at the left lower sternal border that increases in intensity when moving from supine to standing.
- A) Clear the adolescent for unrestricted sports participation.
- B) Order a resting electrocardiogram and an echocardiogram.✓
- C) Prescribe a beta-blocker and restrict participation.
- D) Refer the adolescent for an exercise stress test.
💡 Key Takeaway
Murmurs that increase with standing suggest hypertrophic cardiomyopathy and require evaluation with an ECG and echocardiogram.
Show rationale
The correct answer is B. This presentation is highly suspicious for hypertrophic cardiomyopathy, characterized by a systolic murmur that increases with maneuvers that decrease venous return, such as standing or the Valsalva maneuver. Because this condition is a leading cause of sudden cardiac death in young athletes, the safest approach is to order a resting electrocardiogram and echocardiogram to evaluate structural abnormalities before granting clearance. Option A is incorrect because clearing this athlete risks a fatal cardiac event. Option C is incorrect because prescribing a beta-blocker is premature without a confirmed diagnosis. Option D is incorrect because an exercise stress test is not the initial diagnostic modality for structural heart disease and could potentially trigger a lethal arrhythmia in an undiagnosed patient.
Question 5
A 58-year-old male with hypertension presents with crushing chest pain radiating to the left jaw. His in-office electrocardiogram reveals new ST-segment elevations in leads V2-V4.
- A) Anterior wall myocardial infarction✓
- B) Chronic stable angina pectoris
- C) Acute viral pericarditis infection
- D) Unstable angina pectoris presentation
💡 Key Takeaway
Localized ST-segment elevations with ischemic chest pain indicate an acute ST-elevation myocardial infarction.
Show rationale
Crushing chest pain radiating to the jaw with new ST-segment elevations in the precordial leads indicates an anterior wall myocardial infarction, a severe form of ACS. Chronic stable angina does not cause acute ST elevations or resting pain. Unstable angina lacks ST-segment elevations on an ECG. Acute pericarditis typically shows diffuse ST elevations across multiple vascular territories, not localized strictly to the anterior leads.
Question 6
A 52-year-old male with no prior medical history has an initial office blood pressure of 148/94 mm Hg. He denies headaches, visual changes, or chest pain. What is the most appropriate next step in his evaluation?
- A) Initiate a thiazide diuretic medication and schedule a prompt clinical follow-up.
- B) Initiate a calcium channel blocker and schedule a prompt clinical follow-up.
- C) Arrange out-of-office blood pressure monitoring to accurately confirm the clinical diagnosis.✓
- D) Arrange an immediate echocardiogram study to accurately assess target organ damage.
💡 Key Takeaway
Out-of-office blood pressure monitoring is required to confirm hypertension before initiating pharmacological therapy.
Show rationale
A single elevated office blood pressure without signs of target organ damage is insufficient to diagnose hypertension. Guidelines recommend out-of-office monitoring to confirm the diagnosis before starting medication. Option C is correct. Options A and B are premature because a definitive diagnosis has not yet been established. Option D is unnecessary as the patient is completely asymptomatic and lacks any clinical evidence suggesting a hypertensive emergency or acute target organ damage.
Question 7
A seventy-five-year-old female with coronary artery disease is taking 50 mcg of levothyroxine daily. Her current TSH is 0.1 mIU/L (reference 0.4-4.0 mIU/L), and she reports new-onset intermittent palpitations. Her electrocardiogram shows normal sinus rhythm. Which action is most appropriate?
- A) Maintain the current dose and recheck the TSH later.
- B) Increase the levothyroxine dose by twelve micrograms daily.
- C) Switch the patient from levothyroxine to daily liothyronine.
- D) Decrease the levothyroxine dose by twelve micrograms daily.✓
💡 Key Takeaway
Over-replacement of levothyroxine in older adults with coronary artery disease requires a dose decrease to prevent arrhythmias.
Show rationale
A suppressed TSH indicates over-replacement of thyroid hormone, which significantly increases the risk of atrial fibrillation and exacerbates angina, especially in older adults with known coronary artery disease. Decreasing the dose is essential to return the TSH to a safe target range. Maintaining the dose ignores the active cardiac symptoms and suppressed labs. Increasing the dose or adding liothyronine would worsen the thyrotoxic state and further increase her cardiovascular risk.
Question 8
A 58-year-old male with a recent myocardial infarction was prescribed atorvastatin 80 mg daily. His baseline LDL was 160 mg/dL. He returns for a twelve-week follow-up to evaluate his pharmacotherapeutic outcomes.
- A) An LDL level of 75 mg/dL indicates an optimal therapeutic response.✓
- B) An LDL level of 95 mg/dL indicates an optimal therapeutic response.
- C) An LDL level of 110 mg/dL indicates an optimal therapeutic response.
- D) An LDL level of 130 mg/dL indicates an optimal therapeutic response.
💡 Key Takeaway
High-intensity statin therapy should achieve at least a 50% reduction in baseline LDL levels.
Show rationale
Atorvastatin 80 mg is a high-intensity statin expected to lower LDL by at least 50 percent. With a baseline LDL of 160 mg/dL, a 50% reduction targets an LDL of 80 mg/dL or lower. Option A is correct because 75 mg/dL successfully exceeds this 50% reduction threshold, demonstrating an optimal pharmacotherapeutic outcome for secondary prevention. Options B, C, and D are incorrect because they represent reductions of less than 50%, indicating an inadequate response that would require further clinical intervention, such as adherence counseling or the addition of nonstatin therapies.
Question 9
A 70-year-old female, post-MI 6 weeks ago, is preparing for cardiac rehabilitation. Her medications include aspirin, ticagrelor, and metoprolol. Today, her blood pressure is 145/92 mmHg and her ejection fraction is 38%. Which pharmacological adjustment is indicated?
- A) Initiate an angiotensin-converting enzyme inhibitor to improve cardiac remodeling.✓
- B) Increase the metoprolol dosage to achieve strict normotensive parameters.
- C) Add a calcium channel blocker to reduce peripheral vascular resistance.
- D) Discontinue the ticagrelor to minimize bleeding risks during exercise.
💡 Key Takeaway
ACE inhibitors are essential for post-MI tertiary prevention, especially in patients with a reduced ejection fraction.
Show rationale
For tertiary prevention following a myocardial infarction, particularly in patients with a `reduced ejection fraction`, initiating an `angiotensin-converting enzyme inhibitor` is strongly indicated. This medication class helps prevent adverse cardiac remodeling, reduces mortality, and effectively manages concurrent hypertension. Option B is incorrect because while beta-blockers are essential post-myocardial infarction, simply maximizing the metoprolol dosage does not provide the specific myocardial remodeling benefits that ACE inhibitors offer for a reduced ejection fraction. Option C is wrong because non-dihydropyridine calcium channel blockers can actually worsen heart failure outcomes, and dihydropyridines are not considered first-line therapy in this scenario. Option D is dangerous and incorrect; dual antiplatelet therapy with aspirin and ticagrelor is standard of care following a myocardial infarction to prevent stent thrombosis and recurrent ischemic events, regardless of exercise participation.
Question 10
A 40-year-old female presents with a persistent sour taste in mouth and a chronic cough. She reports frequent morning throat clearing but notes her vague chest pain is unaltered by meals. She does not take NSAIDs. Which of the following is the most likely diagnosis?
- A) Gastric peptic ulceration
- B) Duodenal peptic ulceration
- C) Extraesophageal reflux disease✓
- D) Nonulcer functional dyspepsia
💡 Key Takeaway
Atypical or extraesophageal GERD often presents with chronic cough, throat clearing, and water brash rather than classic heartburn.
Show rationale
This patient is exhibiting classic signs of atypical GERD, also known as extraesophageal reflux. Symptoms such as a sour taste (water brash), chronic cough, and morning throat clearing occur when gastric contents micro-aspirate into the larynx or pharynx. Gastric and duodenal peptic ulcerations are incorrect because they present with localized epigastric pain that is distinctly altered by the consumption of meals, which this patient lacks. Nonulcer functional dyspepsia presents with early satiety, postprandial fullness, or epigastric burning, rather than laryngeal irritation and a sour taste in the mouth.
