Cardiovascular System

A 72-year-old man arrives at the emergency department via ambulance with sudden-onset, severe respiratory distress that woke him from sleep $45$ minutes ago. He has a history of poorly controlled essential hypertension, hyperlipidemia, and a 40-pack-year smoking history. Temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $225/118$ mm Hg, pulse is $112$/min, and respirations are $28$/min. Pulse oximetry shows an oxygen saturation of $86\%$ on room air. He is diaphoretic, speaking in one-word sentences, and using accessory muscles of respiration. Jugular venous distention is present when sitting upright. Auscultation reveals diffuse bilateral expiratory wheezes and bibasilar crackles. Cardiac examination shows regular tachycardia with a prominent S3 gallop. The electrocardiogram displays sinus tachycardia and voltage criteria for left ventricular hypertrophy without ischemic ST-segment or T-wave changes. Which of the following is the most appropriate next step in management?

During a cardiology clinical rotation, a group of medical students is learning to recognize distinct physical examination signs that point to specific underlying cardiac pathologies. Different arterial pulse contours can provide crucial clues to a patient's hemodynamic status. Match the following characteristic arterial pulse findings with their most commonly associated cardiovascular condition.

During a clinical skills workshop, medical students are reviewing the physiological effects of various dynamic bedside maneuvers on cardiac murmurs. Understanding how preload and afterload alter hemodynamics is critical for distinguishing similar-sounding murmurs. Match each cardiac pathology with its characteristic auscultatory response to these dynamic maneuvers.

An $58$-year-old male with a history of poorly controlled hypertension is evaluated in the emergency department for severe, abrupt-onset chest pain radiating to his upper back. He describes the pain as "tearing" and rates it a $10$ out of $10$. He appears diaphoretic and in severe distress. Blood pressure is $215/115$ mm Hg in the right arm and $175/90$ mm Hg in the left arm. Heart rate is $115$/min. Neurologic examination is unremarkable. An electrocardiogram shows sinus tachycardia and voltage criteria for left ventricular hypertrophy. A portable chest radiograph reveals a widened mediastinum.

Arrange the following next steps in patient management in the optimal chronological sequence.

A 62-year-old man is brought to the emergency department by ambulance after experiencing sudden-onset, severe epigastric and lower chest pain for the past 90 minutes. He describes the pain as a "heavy weight" and reports associated nausea and profuse sweating. His medical history includes type 2 diabetes mellitus, peripheral arterial disease, and a 40-pack-year smoking history. Current medications include metformin and atorvastatin. On arrival, his temperature is 36.8 °C (98.2 °F), blood pressure is 82/50 mmHg, pulse is 112/min, and respiratory rate is 18/min. Pulse oximetry is 97% on room air. Physical examination reveals clear lungs to auscultation bilaterally. Jugular venous pulsations are visible 10 cm above the sternal angle while the patient is seated at a 45-degree angle. Cardiac auscultation reveals a regular rhythm without murmurs or gallops. The extremities are cool and clammy. An electrocardiogram reveals sinus tachycardia with 3-mm ST-segment elevations in leads II, III, and aVF, as well as 2-mm ST-segment depressions in leads I and aVL. The patient is administered chewable aspirin and ticagrelor. Which of the following is the most appropriate initial step to stabilize this patient's hemodynamics?

A 65-year-old man with end-stage renal disease secondary to diabetic nephropathy is brought to the emergency department due to progressive generalized weakness and lethargy. He missed his last two scheduled hemodialysis sessions. His current heart rate is 54/min and blood pressure is 105/60 mm Hg. A stat basic metabolic panel is drawn, and the physician orders continuous cardiac monitoring. Assuming his serum potassium continues to rise untreated, arrange the following electrocardiographic (ECG) changes in the chronological order they are expected to appear.

A medical student is reviewing characteristic jugular venous pressure (JVP) waveform abnormalities during a cardiology rotation. Match each specific JVP finding with its most likely underlying cardiovascular pathology.

A 38-year-old man is evaluated in the hospital on day 3 of admission for high fever, chills, and progressive shortness of breath. He has a history of bipolar disorder, asthma, and intravenous drug use. On admission, blood cultures were drawn, and empirical intravenous vancomycin and cefepime were initiated. Today, the patient reports feeling persistently fatigued and depressed, stating he has been in a 'down state' for the past month. He is currently taking lithium. Temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $110/70\text{ mm Hg}$, pulse is $105/\text{min}$, and respirations are $22/\text{min}$. Physical examination reveals a grade 3/6 holosystolic murmur at the left lower sternal border that increases in intensity with inspiration. Scattered bilateral lung crackles are present. Laboratory studies show:

An echocardiogram demonstrates a 1.5-cm mobile vegetation on the tricuspid valve with severe tricuspid regurgitation. Blood cultures from admission have grown methicillin-susceptible *Staphylococcus aureus* (MSSA). Which of the following is the most appropriate next step in management?

A $32$-year-old female patient is assessed on hospital day $4$. She was initially admitted for high fevers, rigors, and pleuritic chest pain. Her past medical history is significant for major depressive disorder managed with citalopram, and severe opioid use disorder. On the day of admission, physical examination revealed a pan-systolic murmur at the left lower sternal border that augmented during inspiration. Blood cultures from admission grew methicillin-susceptible *Staphylococcus aureus* (MSSA). A transthoracic echocardiogram showed a $1.6$-cm oscillating mass on the tricuspid valve. She was appropriately started on targeted therapy with continuous intravenous nafcillin.

Currently, she reports mild improvement in her chest pain but notes a persistent cough. Her temperature is $37.9^\circ \text{C}$ ($100.2^\circ \text{F}$), blood pressure is $114/70$ mmHg, pulse is $92$/min, and respiratory rate is $18$/min. Pulse oximetry shows $95\%$ on room air. Auscultation of the lungs reveals coarse crackles in the periphery of both lung fields. The cardiac examination is unchanged from admission. There is no jugular venous distention and no peripheral edema.

Laboratory tests reveal:
Leukocyte count: $12,200$/mm $^3$
Thyroid-stimulating hormone (TSH): $1.4\ \mu\text{U/mL}$ (Normal: $0.5 - 5.0\ \mu\text{U/mL}$)
Free thyroxine (T4): $1.1\ \text{ng/dL}$ (Normal: $0.9 - 1.7\ \text{ng/dL}$)
Total triiodothyronine (T3): $62\ \text{ng/dL}$ (Normal: $80 - 200\ \text{ng/dL}$)

A repeat chest radiograph demonstrates several new, small cavitary lesions scattered throughout the peripheral lung fields bilaterally.

Which of the following is the most appropriate next step in the management of this patient?

A $68$-year-old woman is rapidly assessed in the cardiac telemetry unit due to sudden-onset severe dyspnea and progressive confusion. She was admitted $3$ days ago for an ST-segment elevation myocardial infarction involving the inferior leads, which was treated with percutaneous coronary intervention of the right coronary artery.

Current vital signs include a temperature of $36.7^\circ\text{C}$ ($98.1^\circ\text{F}$), blood pressure of $78/48\text{ mmHg}$, heart rate of $122/\text{min}$, and respiratory rate of $32/\text{min}$. Oxygen saturation is $84\%$ on high-flow supplemental oxygen.

Physical examination reveals cold, clammy extremities and significant jugular venous distention. Lung auscultation demonstrates diffuse bilateral crackles and prominent expiratory wheezes. Cardiac auscultation reveals a new, harsh, grade $4/6$ holosystolic murmur heard best at the apex with radiation to the axilla.

Point-of-care testing shows a serum lactate of $5.1\text{ mmol/L}$. A thyroid panel drawn earlier as part of an altered mental status workup shows a thyroid-stimulating hormone (TSH) level of $1.1\text{ \mu U/mL}$ (normal: $0.5-5.0\text{ \mu U/mL}$) and a free T4 of $0.9\text{ ng/dL}$ (normal: $0.9-2.4\text{ ng/dL}$).

Which of the following is the most appropriate next step in the management of this patient?

A 64-year-old man comes to the primary care clinic for a routine evaluation of worsening shortness of breath and a dry, hacking cough over the past 3 months. He reports that the cough is particularly bothersome at night and often wakes him from sleep, forcing him to prop himself up with three pillows. His medical history is significant for hypertension, type 2 diabetes mellitus, and a 35-pack-year smoking history, though he quit smoking a decade ago. Current medications include lisinopril, amlodipine, and metformin. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 158/92 mm Hg, pulse of 88/min, and respirations of 18/min. BMI is 29 kg/m². Pulse oximetry is 96% on room air. On physical examination, the lungs are clear to auscultation bilaterally. Cardiac examination reveals a regular rate and rhythm, but the point of maximal impulse is palpated at the anterior axillary line in the sixth intercostal space. A grade 2/6 holosystolic murmur is heard best at the cardiac apex. There is 1+ pitting edema in the bilateral ankles. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient's condition?

A 55-year-old woman with a recent diagnosis of advanced non-small cell lung cancer is brought to the emergency department due to worsening shortness of breath, profound weakness, and lightheadedness over the past 48 hours. On physical examination, she is diaphoretic and in moderate respiratory distress. Her blood pressure is 82/60 mmHg, heart rate is 118/min, and respiratory rate is 24/min. Jugular venous pressure is estimated at 14 cm H₂O. Auscultation reveals distant heart sounds and clear lung fields bilaterally. Her systolic blood pressure decreases by 18 mmHg during inspiration.

Arrange the following diagnostic and management steps in the most appropriate chronological order for this patient.

Match each physical examination finding describing a characteristic cardiac murmur to the most likely underlying cardiovascular condition or pathology.

A 62-year-old man is evaluated in the cardiac intensive care unit following an acute anterior myocardial infarction. On hospital day 2, the telemetry monitor suddenly alarms, demonstrating a chaotic, irregular rhythm with an undulating baseline and no discernible P waves, QRS complexes, or T waves. The patient is found unresponsive, apneic, and pulseless. The emergency response team arrives immediately with a defibrillator, and chest compressions are initiated. Arrange the following subsequent interventions in the most appropriate chronological sequence according to standard Advanced Cardiovascular Life Support (ACLS) guidelines for this presentation.

A 69-year-old man comes to the emergency department reporting a two-week history of progressive abdominal bloating, right-sided abdominal pain, and swelling in both legs. He also reports worsening shortness of breath over the past six months, noting that he now has to stop and rest after walking just one block. He has a 50-pack-year smoking history and has not received routine medical care for over a decade. He does not take any medications.

Vital signs are temperature 37.0°C (98.6°F), blood pressure 110/70 mm Hg, pulse 95/min, and respirations 22/min. Pulse oximetry shows 85% on room air.

Physical examination shows central cyanosis. The jugular venous pressure is estimated at 14 cm H2O. The anteroposterior diameter of the chest is increased. Lung auscultation reveals globally diminished breath sounds and a prolonged expiratory phase, with no crackles or wheezes. Cardiac examination demonstrates a prominent parasternal lift and an accentuated pulmonic component of the second heart sound. A high-pitched, holosystolic murmur is heard at the left lower sternal border; the intensity of the murmur increases during inspiration. The abdomen is distended; the liver is palpable 5 cm below the right costal margin and is pulsatile. There is 3+ pitting edema of the lower extremities bilaterally.

Initial laboratory studies show:
Hemoglobin: $18.2 \text{ g/dL}$
Leukocyte count: $8,500/\text{mm}^3$
Platelet count: $210,000/\text{mm}^3$
Brain natriuretic peptide (BNP): $420 \text{ pg/mL}$

Arterial blood gas analysis on room air:
$\text{pH}$: $7.37$
$\text{PaCO}_2$: $54 \text{ mm Hg}$
$\text{PaO}_2$: $52 \text{ mm Hg}$
$\text{HCO}_3^-$: $30 \text{ mEq/L}$

A chest radiograph shows hyperlucent lung fields, flattened hemidiaphragms, and prominent central pulmonary arteries without pulmonary venous congestion or pleural effusions.

Which of the following therapies is most likely to improve long-term survival in this patient?

A 69-year-old man is brought to the emergency department at 3:00 AM due to severe shortness of breath that awoke him from sleep. The patient states he has been feeling increasingly fatigued over the past 3 days and has noticed swelling in both of his lower legs. His past medical history includes hypertension, hyperlipidemia, and a 45-pack-year smoking history. He admits to poor adherence to his prescribed daily medications. On arrival, his temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $172/96\text{ mmHg}$, pulse is $115/\text{min}$, and respiratory rate is $26/\text{min}$. Pulse oximetry shows $89\%$ on room air. Physical examination reveals a patient in moderate respiratory distress, sitting upright on the edge of the stretcher. The jugular venous pressure is visibly elevated to $11\text{ cm H}_2\text{O}$. Lung auscultation demonstrates diffuse expiratory wheezes and prominent bibasilar crackles. Cardiac examination reveals a tachycardic, regular rhythm with a third heart sound ($S_3$). There is 2+ pitting edema extending up to the knees bilaterally. Which of the following is the most appropriate initial pharmacologic therapy for this patient?

A $71$-year-old male is evaluated in the emergency department due to severe shortness of breath that has progressively worsened over the last two days. The patient reports that his breathing becomes especially difficult when he lies flat in bed, requiring him to sleep in a recliner chair. His medical history includes hypertension and a $45$-pack-year smoking history. He currently takes amlodipine. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $172/98$ mmHg, pulse is $112$/min, and respirations are $28$/min. Pulse oximetry shows $89\%$ on room air. Physical examination reveals an anxious patient in mild respiratory distress. Auscultation of the lungs demonstrates diffuse, bilateral expiratory wheezes and a prolonged expiratory phase. Cardiac auscultation reveals a regular tachycardia; an extra, low-pitched heart sound is heard shortly after the second heart sound at the cardiac apex. The apical impulse is displaced laterally. There is trace bilateral pitting edema of the lower extremities. Bedside chest radiography shows an enlarged cardiac silhouette, prominent pulmonary vasculature, and prominent septal lines. Which of the following is the most likely primary underlying mechanism for this patient's acute respiratory symptoms?

A 54-year-old woman is brought to the emergency department due to the sudden onset of severe, tearing chest pain that radiates to her upper back. The pain began 45 minutes ago while she was lifting heavy furniture. She has a history of poorly controlled hypertension and tobacco use. Her blood pressure is 210/115 mm Hg in the right arm and 175/95 mm Hg in the left arm. Her pulse is 114/min and regular. Physical examination reveals a new decrescendo diastolic murmur heard best at the right upper sternal border. Electrocardiography shows sinus tachycardia with left ventricular hypertrophy, but no acute ischemic changes. Initial portable chest radiography demonstrates a widened mediastinum. Arrange the following management steps in the most appropriate chronological order.

While working in the urgent care clinic, a physician evaluates a $32$-year-old female patient complaining of a racing heartbeat that started abruptly while she was reading a book. She reports no chest discomfort, dyspnea, or lightheadedness. Her blood pressure is $122/78$ mmHg, and her radial pulse is rapid and weak. A $12$-lead electrocardiogram is obtained and displays a perfectly regular tachycardia at $175$ beats per minute with narrow QRS complexes and no discernible P waves.

Assuming she remains hemodynamically stable but the arrhythmia does not resolve with initial interventions, arrange the following management steps in the standard chronological sequence for this condition, concluding with definitive long-term therapy.

While staffing the cardiac intensive care unit, a physician assumes care of a $66$-year-old male admitted directly from the prehospital setting. Paramedics were called after the patient experienced the sudden onset of crushing retrosternal chest pain and diaphoresis while resting at home. A prehospital $12$-lead electrocardiogram demonstrated marked ST-segment elevations in leads II, III, and aVF, with reciprocal depressions in leads I and aVL. Upon arrival, the patient appears ashen and complains of persistent chest discomfort and profound lightheadedness. Vital signs are temperature $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure $82/50\text{ mm Hg}$, heart rate $54\text{/min}$ (sinus rhythm), and respiratory rate $16\text{/min}$. Pulse oximetry is $96\%$ on ambient air. Physical examination reveals elevated jugular venous pressure with prominent x and y descents. The lung fields are completely clear to auscultation bilaterally. Cardiac auscultation reveals a regular rhythm with no murmurs, though a right-sided S4 is audible. Point-of-care laboratory testing shows an arterial pH of $7.32$, $\text{pCO}_2$ of $36\text{ mm Hg}$, and a serum lactate of $3.8\text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient?