Cardiovascular System

A 64-year-old man is brought to the emergency department via ambulance due to the sudden onset of severe, "tearing" chest pain that radiates to his interscapular region. He has a history of poorly controlled hypertension. On arrival, he appears diaphoretic and in severe distress. Blood pressure is 210/115 mm Hg in the right arm and 160/90 mm Hg in the left arm, with a heart rate of 112/min. Physical examination reveals a new early diastolic decrescendo murmur heard best at the right upper sternal border. An electrocardiogram shows sinus tachycardia with left ventricular hypertrophy, but no acute ischemic changes. A portable chest radiograph reveals a widened mediastinum. Intravenous access and continuous hemodynamic monitoring have been established.

Arrange the following management steps in the most appropriate sequential order for this patient's acute presentation.

Progressive respiratory distress and a persistent nighttime cough prompt a $68$-year-old woman to seek medical evaluation at a local urgent care clinic. She states that over the past $4$ days, she has been unable to sleep lying flat and has needed to prop herself up with three pillows. Her medical history includes hypertension, type 2 diabetes mellitus, a myocardial infarction three years prior, and a $30$-pack-year smoking history. She currently uses an as-needed albuterol inhaler. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $156/94 \text{ mm Hg}$, heart rate of $110/\text{min}$, and respiratory rate of $26/\text{min}$. Pulse oximetry reveals an oxygen saturation of $91\%$ on room air. Physical examination demonstrates prominent jugular venous distention when the patient is seated at a $45^\circ$ angle. Auscultation of the lungs reveals diffuse expiratory wheezes bilaterally and dullness to percussion at the bases. Cardiac auscultation identifies a regular tachycardia and a third heart sound (S3) gallop. A point-of-care arterial blood gas demonstrates a pH of $7.48$, $\text{PaCO}_2$ of $30 \text{ mm Hg}$, and $\text{PaO}_2$ of $64 \text{ mm Hg}$. Which of the following is the most appropriate initial step in management for this patient?

An intensive care unit team is reviewing pulmonary artery catheterization data for several critically ill patients. Match each patient's clinical presentation with their expected central hemodynamic profile. (Note: Arrows indicate relative changes: $\uparrow$ increased, $\downarrow$ decreased, $\leftrightarrow$ normal or unchanged).

Correlate the following specific jugular venous pulse (JVP) waveform abnormalities with the underlying cardiovascular pathology that most classically produces them.

A 65-year-old woman is evaluated in the hospital on postoperative day 2 following an elective total right knee arthroplasty due to sudden-onset palpitations, severe shortness of breath, and lightheadedness. Her medical history includes hypertension, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. Her temperature is 37.9°C (100.2°F), blood pressure is 82/50 mm Hg, heart rate is 148/min, and respiratory rate is 26/min. Pulse oximetry is 91% on 2 L/min of oxygen via nasal cannula. On physical examination, the patient appears distressed and diaphoretic. Her extremities are cool to the touch with delayed capillary refill. Jugular venous distension is present. Lung auscultation reveals bibasilar crackles and scattered expiratory wheezes. Cardiac examination shows an irregularly irregular rhythm with a rapid rate and no distinct murmurs. The right knee surgical site is intact with expected mild swelling and no purulent drainage. An electrocardiogram demonstrates an irregularly irregular rhythm with narrow QRS complexes and absent P waves. Which of the following is the most appropriate immediate next step in management?

Match each patient's clinical presentation and response to dynamic auscultatory maneuvers with the corresponding underlying hemodynamic mechanism.

A $68$-year-old woman arrives at the urgent care clinic reporting severe, progressively worsening difficulty breathing over the last $48$ hours. She notes that she has been waking up gasping for air in the middle of the night and now requires sleeping in her recliner to breathe comfortably. Her past medical history includes long-standing high blood pressure and diet-controlled type $2$ diabetes mellitus. She smoked cigarettes for $30$ years but quit a decade ago. Vital signs show a blood pressure of $162/96$ mm Hg, heart rate of $105$/min, and respiratory rate of $24$/min. Pulse oximetry indicates $92\%$ oxygen saturation on ambient air. Physical examination demonstrates noticeable distension of the neck veins while sitting upright. Lung auscultation reveals bilateral crackles at the bases. Cardiac auscultation detects an extra low-pitched sound occurring just after the second heart sound. Moderate pitting edema is present in both lower legs. Which of the following is the most appropriate initial pharmacological intervention to relieve this patient's respiratory distress?

Match the following classic physical examination auscultation findings with the most likely underlying valvular pathology.

A $34$-year-old primigravida at $37$ weeks gestation is evaluated in the obstetric triage unit for worsening difficulty breathing over the past week. She states that she becomes excessively winded when walking up a single flight of stairs and has recently started using three pillows to sleep comfortably at night. She has a past medical history of mild persistent asthma, for which she occasionally uses an inhaled corticosteroid. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $118/78\text{ mmHg}$, pulse of $110/\text{min}$, and respiratory rate of $22/\text{min}$. Pulse oximetry is $94\%$ on room air. Physical examination reveals prominent distension of the neck veins while sitting at a $45$-degree incline. Chest auscultation reveals fine crackles at the bilateral lung bases. Cardiac auscultation reveals a regular tachycardia and an extra, low-pitched sound in early diastole. There is $2+$ pitting edema extending to the mid-shins bilaterally. Which of the following is the most appropriate next step in patient care?

Match each of the following classic arterial pulse abnormalities with the cardiovascular pathology most commonly associated with its presentation.

A 55-year-old male comes to the outpatient clinic reporting a 3-week history of swelling in both of his ankles. He mentions that his shoes feel uncomfortably tight by the end of the day. One month ago, he was diagnosed with primary hypertension and was started on amlodipine monotherapy. He denies any difficulty breathing, waking up at night gasping for air, chest discomfort, or recent travel. Vital signs are within normal limits, with a blood pressure of 126/80 mm Hg. Physical examination reveals 2+ pitting edema over the bilateral medial malleoli. The overlying skin is intact, with no erythema, warmth, or tenderness. Jugular venous pressure is 6 cm H2O. Lungs are clear to auscultation bilaterally, and cardiac auscultation reveals a regular rate and rhythm with no extra heart sounds. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old man presents to the clinic with a three-week history of a nonproductive cough and progressively worsening shortness of breath. He reports that his breathing becomes particularly difficult when he lies down to sleep at night, forcing him to prop himself up with three pillows. His medical history includes hypertension, osteoarthritis of the knees, and a 25-pack-year smoking history. Three weeks ago, he was evaluated for worsening knee pain and elevated blood pressure, at which time naproxen and amlodipine were added to his daily regimen. Temperature is 37.0°C (98.6°F), blood pressure is 152/92 mm Hg, pulse is 92/min, and respirations are 20/min. BMI is 31 kg/m². Lung auscultation reveals diffuse expiratory wheezing with no crackles. Cardiac examination shows a regular rhythm with normal S1 and S2; a faint, low-frequency sound is heard just after S2 at the cardiac apex. Trace bilateral pitting edema is present at the ankles. Which of the following is the most likely pathophysiologic mechanism underlying this patient's current respiratory symptoms?

Match the following pathophysiological states or clinical conditions with their most characteristic electrocardiogram (ECG) finding.

A 69-year-old woman is brought to the emergency department due to severe shortness of breath that awakened her from sleep 2 hours ago. She has a history of hypertension, type 2 diabetes mellitus, and a 40-pack-year smoking history. Her current medications include amlodipine and metformin. Her temperature is 36.8°C (98.2°F), blood pressure is 172/98 mm Hg, pulse is 115/min, and respirations are 26/min. Pulse oximetry is 89% on room air. Physical examination reveals elevated jugular venous pressure. Lung auscultation demonstrates bilateral basilar crackles and diffuse expiratory wheezing. Cardiac auscultation reveals a regular tachycardia with a prominent S3 gallop. There is 1+ bilateral lower extremity pitting edema. Which of the following diagnostic findings is most likely to be present in this patient?

A $64$-year-old man is brought to the emergency department by ambulance due to the sudden onset of severe, "tearing" chest pain that radiates to his interscapular region. He has a history of poorly controlled hypertension. On arrival, he appears diaphoretic and in severe distress. His blood pressure is $210/115\text{ mmHg}$ in the right arm and $170/95\text{ mmHg}$ in the left arm. His heart rate is $115\text{/min}$. A portable chest radiograph reveals a widened mediastinum. An acute aortic dissection is highly suspected. Arrange the following next steps in the most appropriate chronological sequence for the initial management of this patient.

Match each of the following specific cardiomyopathies with its most characteristic echocardiographic finding.

A 71-year-old retired teacher with a 45-pack-year smoking history is brought to the emergency department at 2:00 AM by his spouse due to sudden, severe respiratory distress. The patient states he was awakened from sleep by a feeling of suffocation. His medical history includes essential hypertension and moderate chronic obstructive pulmonary disease, for which he uses a daily long-acting muscarinic antagonist. Vital signs show a temperature of 36.8°C (98.2°F), blood pressure of 182/105 mm Hg, heart rate of 115/min, and respiratory rate of 28/min. Pulse oximetry is 87% on room air. Physical examination reveals a patient in obvious distress, using accessory muscles of respiration. The jugular venous pressure is estimated at 11 cm H2O, and sustained manual compression of the mid-abdomen results in a persistent 4 cm elevation of the jugular venous column. Pulmonary auscultation reveals widespread, high-pitched expiratory wheezes without any audible crackles. Cardiac examination is notable for a regular tachycardia and a low-frequency sound occurring shortly after the second heart sound, best heard over the fifth intercostal space at the midclavicular line. A portable chest radiograph displays hyperlucent lung fields with flattened diaphragms, accompanied by vascular redistribution to the upper lung zones and distinct bronchial wall thickening. Based on the clinical presentation, which of the following sets of hemodynamic findings is most likely present in this patient?

A 32-year-old man with a history of intravenous drug use is admitted to the intensive care unit with a 4-day history of high fever, chills, and pleuritic chest pain. On physical examination, his temperature is 39.2°C (102.6°F), blood pressure is 110/65 mmHg, pulse is 112/min, and respirations are 22/min. Cardiovascular examination reveals a 3/6 holosystolic murmur best heard at the left lower sternal border that increases in intensity with inspiration. The lungs are clear to auscultation bilaterally. Empiric therapy with intravenous vancomycin and cefepime is initiated after blood cultures are drawn.

On hospital day 3, the patient develops acute respiratory distress. His oxygen saturation drops to 86% on room air. A chest radiograph reveals multiple bilateral nodular opacities with central cavitation. Echocardiography shows a 1.5-cm, highly mobile vegetation on the tricuspid valve with moderate tricuspid regurgitation. The left ventricular ejection fraction is 60%. All four blood culture bottles return positive for methicillin-susceptible Staphylococcus aureus (MSSA).

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

An urgent care clinic evaluates a $74$-year-old male who reports four days of worsening shortness of breath and a persistent dry cough. He notes that lying flat in bed induces a feeling of suffocation, forcing him to sleep in a recliner for the past two nights. His medical history is notable for a myocardial infarction three years ago, essential hypertension, hyperlipidemia, and a $45$-pack-year smoking history. Current medications include aspirin, lisinopril, and atorvastatin. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $158/92\text{ mm Hg}$, pulse of $112\text{/min}$, and respiratory rate of $24\text{/min}$. Pulse oximetry is $89\%$ on room air. The patient appears anxious and is using accessory muscles of respiration. Examination of the neck shows distention of the jugular veins when seated at a $45^\circ$ angle. Pulmonary auscultation reveals diffuse expiratory wheezing and bibasilar crackles. Cardiac auscultation reveals a regular tachycardia with a low-pitched extra heart sound heard shortly after $\text{S}_2$. There is $1+$ pitting edema of the lower extremities bilaterally. Which of the following is the most appropriate initial pharmacological intervention for this patient?

Match each clinical presentation of a myocardial infarction complication with its most characteristic hemodynamic finding on right heart catheterization.