Cardiovascular System

A 65-year-old man comes to the clinic reporting a 3-month history of right calf cramping. The discomfort consistently begins after walking approximately three blocks and resolves completely within a few minutes of rest. He has a history of type 2 diabetes mellitus, hypertension, and a 40-pack-year smoking history. His current medications include metformin and lisinopril. Vital signs are within normal limits. On physical examination, the skin of the right lower extremity appears thin and shiny with decreased hair growth. The right dorsalis pedis pulse is diminished compared to the left. Which of the following is the most appropriate initial diagnostic test to evaluate this patient's condition?

A 72-year-old man with a 50-pack-year smoking history and severe chronic obstructive pulmonary disease (COPD) comes to the clinic for evaluation of gradually increasing leg swelling over the past month. He reports his baseline shortness of breath with exertion, but he specifically denies waking up at night gasping for air and states he sleeps comfortably completely flat in his bed. Vital signs show a blood pressure of 128/82 mm Hg, pulse of 88/min, and oxygen saturation of 89% on room air. Physical examination reveals a barrel-shaped chest, distended jugular veins, a palpable parasternal heave, and bilateral 3+ pitting edema of the lower extremities. Auscultation of the lungs reveals distant breath sounds and prolonged expiration, but no crackles. Cardiac auscultation reveals distant heart sounds with no S3 gallop. Which of the following is the most likely primary underlying mechanism for this patient's peripheral edema?

Match each classic auscultatory finding described below with its corresponding valvular heart disease.

A 54-year-old woman with a history of metastatic breast cancer is brought to the emergency department due to progressive shortness of breath, generalized weakness, and lightheadedness over the past three days. She reports that she nearly fainted earlier today while walking to the bathroom. Her temperature is 37.1 C (98.8 F), blood pressure is 82/45 mm Hg, pulse is 122/min, and respirations are 24/min. Her systolic blood pressure decreases by 15 mm Hg during inspiration. Physical examination reveals markedly distended jugular veins. The lungs are clear to auscultation bilaterally. Cardiac auscultation demonstrates distant, muffled heart sounds. Which of the following is the most appropriate next step in the management of this patient?

Match each classic peripheral manifestation of infective endocarditis with its correct clinical description.

A 58-year-old man presents to the emergency department complaining of sudden-onset, severe, crushing substernal chest pain that began 45 minutes ago and radiates to his left jaw. His blood pressure is 140/90 mmHg, heart rate is 92/min, respiratory rate is 16/min, and oxygen saturation is 98% on room air. Physical examination reveals an anxious, diaphoretic patient with normal heart sounds and clear lungs. Arrange the following initial management steps in the most appropriate chronological sequence for this patient.

Paramedics bring a 64-year-old woman to the emergency department due to acute respiratory distress that began 2 hours ago. She reports severe difficulty breathing and the sensation of smothering, which worsens significantly when she tries to lie flat on the stretcher. Her medical history includes long-standing hypertension, diet-controlled type 2 diabetes mellitus, and a 30-pack-year history of cigarette smoking. Upon arrival, her blood pressure is 182/104 mmHg, heart rate is 112/min, and respiratory rate is 26/min. Pulse oximetry shows an oxygen saturation of 88% on room air. Physical examination reveals an anxious patient sitting upright and utilizing accessory muscles of respiration. Jugular venous pressure is visibly elevated. Pulmonary auscultation reveals bilateral basilar crackles and prominent diffuse expiratory wheezing. Cardiac auscultation is notable for a regular tachycardia and an audible S3 gallop. In addition to providing supplemental oxygen, which of the following is the most appropriate initial pharmacological intervention for this patient?

A previously healthy college student evaluates at the university health clinic reporting sharp, stabbing chest pain that started the day before. The discomfort is severely aggravated by lying flat in bed and taking deep breaths, but provides significant relief when the patient is sitting up and leaning forward. Vital signs reveal a temperature of 38.1°C (100.6°F), heart rate of 98/min, and blood pressure of 118/74 mm Hg. An electrocardiogram demonstrates diffuse, concave ST-segment elevations and PR-segment depressions across most limb and precordial leads. Cardiac troponin levels are within normal limits. Which of the following is the most appropriate initial pharmacological treatment for this patient's condition?

A 60-year-old man suddenly collapses in the hospital cafeteria. You are the first healthcare provider on the scene. Arrange the following initial steps of Basic Life Support (BLS) in the correct chronological order for managing this patient.

A 71-year-old man is evaluated at the ambulatory clinic due to worsening exertional dyspnea and lower extremity swelling over the past week. He has a history of long-standing hypertension and a 35-pack-year smoking history. For the last three nights, he has been sleeping in a reclining chair to breathe comfortably. Vital signs show a blood pressure of 160/92 mm Hg, a pulse of 108/min, and a respiratory rate of 24/min. Physical examination demonstrates prominent jugular venous distention, a third heart sound (S3) gallop, bilateral basilar crackles, and scattered end-expiratory wheezes. Bilateral pitting edema is present up to the level of the knees. Which of the following is the most likely underlying cause of this patient's expiratory wheezing?

Match each commonly prescribed cardiovascular medication with its classic clinical adverse effect profile.

Match each classic cardiovascular physical exam or ECG finding with its underlying pathophysiologic mechanism.

During cardiovascular examination, specific palpable and auscultatory findings provide critical insight into a patient's underlying structural and hemodynamic pathology. Match each of the following classic physical examination findings with the primary hemodynamic or structural mechanism responsible for its generation.

Match each patient's presenting electrocardiographic (ECG) pattern and clinical scenario with the most likely corresponding underlying coronary artery pathology or myocardial injury.

A 62-year-old man presents to the emergency department complaining of severe, sudden-onset tearing chest pain that radiates to his back. His blood pressure is 196/112 mm Hg in the right arm and 188/108 mm Hg in the left arm. His heart rate is 114/min. On physical examination, a decrescendo diastolic murmur is heard at the right upper sternal border. An electrocardiogram shows sinus tachycardia with no ischemic changes. A chest radiograph reveals a widened mediastinum. Arrange the following management steps in the most appropriate sequential order for this patient, from initial stabilization to definitive treatment.

An ambulance transports a 70-year-old man to the emergency department for severe dyspnea and a persistent cough that have progressively worsened over the last 72 hours. He notes waking up multiple times at night feeling as though he is suffocating, and he has developed new-onset swelling in his lower legs. His past medical history includes a 45-pack-year smoking habit and chronic obstructive pulmonary disease (COPD), which is managed with a daily tiotropium inhaler. He also has poorly controlled hypertension and has not seen a physician in over five years. He denies having a fever, and his cough yields only a small amount of clear, frothy sputum.

Upon arrival, his temperature is $37.2^\circ\text{C}$, blood pressure is $172/98\text{ mm Hg}$, heart rate is $112\text{/min}$, and respiratory rate is $26\text{/min}$. Pulse oximetry on room air indicates an oxygen saturation of $88\%$.

Physical examination shows a patient in moderate respiratory distress using accessory muscles of respiration. The jugular venous pulse is distended and visible $10\text{ cm}$ above the sternal angle. Auscultation of the lungs reveals a prolonged expiratory phase with widespread, diffuse expiratory wheezing; no crackles are heard. Cardiac auscultation demonstrates tachycardia with a regular rhythm. A distinct, low-frequency extra heart sound is heard in diastole just after the second heart sound, localized to the fifth intercostal space at the midclavicular line. Pitting edema (2+) is present bilaterally extending to the mid-calves.

Arterial blood gas analysis obtained on room air demonstrates:
- pH: $7.30$
- PaCO $_2$: $54\text{ mm Hg}$
- PaO $_2$: $55\text{ mm Hg}$

A chest radiograph displays hyperinflation of the lungs, enlarged central pulmonary arteries, and prominent peribronchial cuffing without focal infiltrates or pleural effusions.

Which of the following is the most appropriate initial pharmacologic intervention for this patient's acute presentation?

Match each classic arterial pulse abnormality with the underlying cardiovascular condition it most strongly suggests.

During bedside rounds in the cardiovascular intensive care unit, an attending physician asks the clinical team to evaluate the central venous pressure waveforms and jugular venous pulsations of several patients. Match each detailed clinical description of a jugular venous pulse abnormality with the underlying structural, valvular, or electrical pathology that best explains its pathophysiology.

A 62-year-old man with a 40-pack-year smoking history and type 2 diabetes mellitus presents with reproducible, severe cramping pain in his right calf after walking two blocks. The pain reliably resolves with 5 minutes of rest. He has no rest pain, ulceration, or gangrene. Examination reveals diminished pedal pulses on the right. His ankle-brachial index (ABI) is 0.65 in the right leg and 1.05 in the left leg. Assuming his symptoms remain persistently lifestyle-limiting despite strict patient compliance with each preceding intervention, arrange the following management steps in the correct guideline-directed sequential order.

During morning rounds in the step-down unit, the medical team evaluates a patient who was admitted three days prior for severe, refractory peripheral edema, abdominal fullness, and exertional dyspnea. The patient, a $55$-year-old individual, has not responded to high-dose intravenous torsemide. Medical history is notable for classical Hodgkin lymphoma in her twenties, which was treated with multi-agent chemotherapy and mantle field radiation, as well as moderate chronic obstructive pulmonary disease.

Vital signs show a blood pressure of $112/74\text{ mm Hg}$, pulse of $92/\text{min}$, and respiratory rate of $18/\text{min}$. Oxygen saturation is $96\%$ on room air. Physical examination demonstrates marked jugular venous distention that paradoxically rises when the patient takes a deep breath. A sharp, high-frequency sound is heard along the left sternal border occurring approximately $0.10\text{ seconds}$ after the second heart sound. The liver edge is palpable $4\text{ cm}$ below the right costal margin. Lungs are clear to auscultation without wheezing.

The team decides to perform simultaneous right and left heart catheterization to clarify the hemodynamic profile. Which of the following findings is most expected in this patient?