Cardiovascular System

A 68-year-old man is brought to the emergency department by emergency medical services due to severe, progressively worsening shortness of breath that began 4 hours ago. He has a history of essential hypertension, type 2 diabetes mellitus, and a 40-pack-year smoking history. He has not seen a physician in three years and does not take any medications currently. Upon arrival, the patient is agitated, diaphoretic, and unable to speak in full sentences. He is sitting upright and leaning forward. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $215/115\text{ mmHg}$, heart rate of $122/\text{min}$, and respiratory rate of $32/\text{min}$. Oxygen saturation is $85\%$ on room air. Jugular venous pulsation is visible $10\text{ cm}$ above the sternal angle. Pulmonary auscultation reveals prolonged expiration with diffuse, loud, bilateral wheezing; no crackles are heard. Cardiac auscultation reveals a regular tachycardia and an extra low-frequency diastolic heart sound heard immediately after S2. The point of maximal impulse is displaced laterally. Bedside electrocardiogram demonstrates sinus tachycardia with voltage criteria for left ventricular hypertrophy. Which of the following is the most appropriate initial pharmacotherapy for this patient?

A 29-year-old woman, gravida 1 para 0, at 28 weeks gestation is brought to the emergency department due to sudden-onset, severe shortness of breath and a cough productive of pink-tinged sputum. She immigrated to the United States two years ago and has not received routine prenatal care. Vital signs show a blood pressure of 110/70 mmHg, a pulse of 118/min, and a respiratory rate of 28/min. Oxygen saturation is 88% on room air. Physical examination reveals a gravid uterus consistent with dates. Auscultation of the lungs demonstrates bilateral basilar crackles. Cardiac examination reveals a loud first heart sound (S1) and a low-pitched, rumbling mid-diastolic murmur heard best at the cardiac apex. Which of the following underlying mechanisms best explains the acute onset of this patient's respiratory symptoms?

A 62-year-old man presents to a rural emergency department with crushing substernal chest pain that began 45 minutes ago. His blood pressure is $130/80\text{ mmHg}$, and his heart rate is $88/\text{min}$. An electrocardiogram reveals $4\text{ mm}$ ST-segment elevations in leads II, III, and aVF. The hospital does not have a cardiac catheterization laboratory. The nearest percutaneous coronary intervention (PCI)-capable center is 150 minutes away by helicopter due to current weather conditions.

Arrange the following management steps in the most appropriate chronological order according to standard guidelines.

A 58-year-old man suddenly collapses while walking in the hospital lobby. He is unresponsive, lacks a palpable pulse, and is not breathing. The emergency response team arrives and attaches a cardiac monitor, which reveals ventricular fibrillation. According to the Advanced Cardiac Life Support (ACLS) algorithm for adult cardiac arrest, arrange the following subsequent management steps in the correct chronological sequence.

A 28-year-old man presents to the emergency department with a 4-day history of high fevers, chills, and sharp, pleuritic chest pain. He also reports a cough productive of scant, blood-tinged sputum. His temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $112/68\text{ mmHg}$, pulse is $118/\text{min}$, and respiratory rate is $22/\text{min}$. Oxygen saturation is $94\%$ on room air. Physical examination reveals prominent needle track marks on his forearms. Cardiac auscultation demonstrates a grade $3/6$ holosystolic murmur at the left lower sternal border; the murmur's intensity increases significantly during inspiration. Pulmonary auscultation reveals scattered crackles in both lung fields. A chest radiograph demonstrates multiple bilateral peripheral nodular opacities, several of which have central cavitation. Three sets of blood cultures are obtained. Which of the following is the most appropriate initial pharmacotherapy for this patient?

A 68-year-old man comes to the emergency department complaining of worsening shortness of breath, a persistent nonproductive cough, and swelling in his legs over the past 4 days. He has a 40-pack-year smoking history and a medical history of hypertension, hyperlipidemia, and type 2 diabetes mellitus. His current medications include amlodipine, lisinopril, atorvastatin, and metformin. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $162/92\text{ mmHg}$, pulse is $106/\text{min}$, and respirations are $24/\text{min}$. Pulse oximetry shows an oxygen saturation of $92\%$ on room air. Physical examination reveals a patient in mild respiratory distress using accessory muscles of respiration. Jugular venous pressure is elevated at $12\text{ cm H}_2\text{O}$. Lung auscultation reveals bilateral diffuse expiratory wheezes and dullness to percussion at both bases. Cardiac examination shows a regular rhythm, tachycardia, and a third heart sound (S3). Trace bilateral pitting edema is present up to the ankles. An electrocardiogram shows sinus tachycardia with no acute ischemic changes. Which of the following is the most appropriate initial therapy for this patient's current condition?

An emergency medical responder brings a 73-year-old retired construction worker to the emergency department after his wife noticed severe swelling in his legs and progressive difficulty breathing over the past three weeks. The patient has a 50-pack-year smoking history but has not been evaluated by a physician in more than a decade. Vital signs show a temperature of 37.1°C, blood pressure of 138/84 mm Hg, pulse of 108/min, and respiratory rate of 24/min. Oxygen saturation is 88% on room air.

Physical examination reveals an increased anteroposterior diameter of the chest. Lung auscultation demonstrates globally decreased breath sounds with a prolonged expiratory phase. Jugular venous pressure is visibly elevated to 11 cm H2O and features a prominent *a* wave. Cardiac examination reveals a pronounced impulse along the left lower sternal border. A soft, high-pitched, blowing, early diastolic murmur is heard best at the second left intercostal space. The liver edge is palpable 4 cm below the right costal margin, and there is 2+ bilateral pitting edema extending to the knees.

A portable chest radiograph demonstrates hyperlucent lung fields, flattened diaphragms, and prominent central pulmonary arteries without pleural effusions or pulmonary infiltrates. Electrocardiography shows right axis deviation and peaked P waves in lead II.

Which of the following is the most likely initiating mechanism for this patient's cardiac findings?

Match each of the following dynamic auscultation findings with the most likely underlying structural or valvular pathology.

A 68-year-old woman is brought to the emergency department via ambulance due to the sudden onset of severe, "tearing" chest pain that radiates to between her shoulder blades. The pain started $45$ minutes ago while she was watching television. She has a history of poorly controlled essential hypertension and tobacco use. On arrival, she is visibly diaphoretic and in acute distress. Her blood pressure is $210/115 \text{ mm Hg}$ in the right arm and $175/95 \text{ mm Hg}$ in the left arm. Her heart rate is $112/\text{min}$, and her respiratory rate is $22/\text{min}$. Oxygen saturation is $96\%$ on room air. Physical examination reveals a new early diastolic decrescendo murmur auscultated best at the right upper sternal border. Neurologic examination is unremarkable. Two large-bore intravenous lines are established.

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

Match each clinical presentation following a recent acute myocardial infarction with the most likely specific structural or inflammatory complication.

An inpatient consultation is requested for a 73-year-old male on the orthopedic surgery ward who developed acute-onset respiratory distress. The patient was admitted 3 days ago for management of right lower extremity cellulitis and has been receiving intravenous cefazolin and continuous normal saline at 125 mL/hr. Medical history is significant for hypertension, type 2 diabetes mellitus, and a 40-pack-year smoking history. Temperature is 37.1°C (98.8°F), blood pressure is 165/95 mm Hg, pulse is 112/min, and respirations are 28/min. Pulse oximetry shows 88% on room air. Physical examination reveals a patient in moderate respiratory distress using accessory muscles. Jugular venous pulsation is visible 11 cm above the sternal angle. Lung auscultation demonstrates diffuse, bilateral end-expiratory wheezes with scattered bibasilar crackles. Cardiac auscultation reveals a regular tachycardia with a prominent early diastolic extra heart sound. Lower extremities show 2+ pitting edema bilaterally extending to the knees. Which of the following is the most appropriate next step in management?

A $65$-year-old man is evaluated in the surgical intensive care unit on postoperative day $4$ following a partial colectomy for recurrent diverticulitis. Over the past $6$ hours, he has developed a fever, chills, and progressively worsening shortness of breath. His medical history is notable for severe chronic obstructive pulmonary disease (COPD) and a known bicuspid aortic valve.

Current vital signs are temperature $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure $82/48\text{ mm Hg}$, pulse $126/\text{min}$ and regular, and respiratory rate $28/\text{min}$. Pulse oximetry shows $88\%$ on room air.

Physical examination reveals a diaphoretic man in acute respiratory distress. Jugular venous distention is present. Chest auscultation reveals diffuse bilateral crackles and scattered wheezes. Cardiac auscultation reveals a new, loud, grade $3/6$ decrescendo diastolic murmur heard best at the left sternal border.

His surgical incisions appear clean and intact. A central venous catheter, placed prior to surgery, remains in the right internal jugular vein, and the insertion site is erythematous and tender.

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

A 68-year-old man is evaluated in the cardiac intensive care unit for sudden-onset severe dyspnea and lightheadedness. He was admitted 4 days ago for an acute inferior myocardial infarction, which was treated with prompt percutaneous coronary intervention of the right coronary artery. His temperature is 38.1°C (100.6°F), blood pressure is 78/50 mmHg, pulse is 122/min, and respirations are 24/min. Pulse oximetry shows 92% on 4 L/min by nasal cannula. Physical examination reveals jugular venous distension up to the angle of the mandible. Lung auscultation is completely clear bilaterally. Cardiac auscultation reveals a rapid rate and a new, harsh holosystolic murmur best heard at the left lower sternal border, accompanied by a palpable thrill. His extremities are cool and clammy. Which of the following is the most appropriate next step in management?

A 59-year-old man presents to the emergency department with sudden-onset, severe, "ripping" chest pain that radiates to his back, between the shoulder blades. His blood pressure is 198/112 mmHg in the right arm and 192/108 mmHg in the left arm. His heart rate is 118/min. Physical examination reveals a faint early diastolic decrescendo murmur at the right sternal border. Electrocardiogram shows sinus tachycardia with no ST-segment or T-wave abnormalities. Chest x-ray demonstrates a widened mediastinum. Arrange the following interventions in the most appropriate sequential order for the initial management of this patient.

A $33$-year-old primigravida at $38$ weeks gestation presents to the obstetric triage unit with a $2$-week history of worsening fatigue, exertional dyspnea, and a persistent dry, nocturnal cough. The patient states she has recently started sleeping in a recliner chair because she feels "smothered" when lying flat in bed. Her pregnancy has been largely uncomplicated, with normal prenatal anatomy scans and glucose tolerance testing. She takes a daily prenatal vitamin. Temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $138/86\text{ mm Hg}$, pulse is $112/\text{min}$, and respirations are $22/\text{min}$. Pulse oximetry is $94\%$ on room air. Physical examination reveals jugular venous distention $8\text{ cm}$ above the sternal angle when sitting at $45$ degrees. Cardiac auscultation demonstrates a regular tachycardia and a low-frequency, early diastolic sound heard best at the apex in the left lateral decubitus position. Lung auscultation reveals fine bibasilar crackles. Bilateral $2+$ pitting pedal edema is present. Fetal heart rate monitoring shows a baseline of $145/\text{min}$ with moderate variability and positive accelerations. Which of the following is the most appropriate next step in the management of this patient?

During cardiovascular physiology rounds, a medical student is asked to interpret the central venous pressure waveforms of various patients. Match each specific jugular venous pulsation (JVP) waveform abnormality with the underlying cardiac pathology that most commonly produces it.

An emergency medical services team brings a 71-year-old male to the resuscitation bay following 48 hours of progressively worsening shortness of breath, rapid heart rate, and increased production of thick, yellowish sputum. He has a documented medical history of chronic obstructive pulmonary disease (COPD), essential hypertension, and major depressive disorder. Current home pharmacological therapies consist of amlodipine, a combined fluticasone-salmeterol inhaler, and citalopram.

Initial vital signs obtained upon arrival demonstrate a temperature of $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure of $128/78\text{ mm Hg}$, heart rate of $138/\text{min}$, and respiratory rate of $26/\text{min}$. Pulse oximetry indicates an oxygen saturation of $85\%$ while breathing ambient air.

Physical assessment highlights a barrel-shaped chest with prominent utilization of accessory muscles of respiration. Thoracic auscultation reveals global expiratory wheezing intermixed with coarse rhonchi. Evaluation of the cardiovascular system demonstrates a tachycardic, irregularly irregular rhythm featuring variable intensity of the first heart sound (S1); no S3 gallop or murmurs are appreciated. The jugular venous pressure is measured at $8\text{ cm H}_2\text{O}$. Trace bilateral lower extremity edema is noted.

A 12-lead electrocardiogram (ECG) reveals an irregularly irregular rhythm with narrow QRS complexes. Closer inspection of lead II identifies varying PR intervals and at least three distinct P-wave morphologies preceding the QRS complexes. The calculated QTc interval is $460\text{ ms}$.

Arterial blood gas parameters on room air are as follows:

Which of the following interventions represents the most appropriate initial management step for this patient's specific cardiac rhythm abnormality?

Match each distinct arterial pulse contour abnormality observed on physical examination to its most closely associated underlying cardiovascular pathology.

A 71-year-old man with a 40-pack-year smoking history and diet-controlled type 2 diabetes mellitus arrives at the emergency department with a 3-day history of progressively worsening shortness of breath. He reports a dry cough that frequently awakens him from sleep. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $165/95\text{ mmHg}$, pulse is $110/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows $89\%$ on room air. Physical examination reveals diffuse expiratory wheezing, a prolonged expiratory phase, and an elevated jugular venous pressure. The physician suspects that an acute cardiovascular condition may be mimicking a primary pulmonary process. Which of the following additional findings would be most specific for confirming an acute cardiogenic etiology for this patient's respiratory distress rather than an exacerbation of chronic obstructive pulmonary disease?

A 24-year-old primigravida at 28 weeks gestation presents to the obstetrical triage unit complaining of worsening shortness of breath and a cough that is occasionally productive of blood-streaked sputum. She immigrated to the United States two years ago and has had limited prior medical care. The patient notes that her breathing is significantly worse when she attempts to lie flat in bed. Temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $108/68\text{ mmHg}$, pulse is $118/\text{min}$ and regular, and respirations are $26/\text{min}$. Pulse oximetry ($SpO_2$) is $92\%$ on room air. Physical examination shows jugular venous distention. Lung auscultation reveals bilateral crackles in the lower lung fields. Cardiac auscultation in the left lateral decubitus position demonstrates a prominent first heart sound ($S_1$) and a low-pitched, mid-diastolic rumble at the apex. Which of the following is the most appropriate next step in patient care?