Cardiovascular System

Match each classic auscultatory finding with its most likely underlying valvular pathology.

A retired 62-year-old teacher visits an urgent care clinic reporting a one-week history of progressively worsening difficulty breathing. She notes a new, persistent cough and states she has been forced to sleep in her living room recliner for the past three nights to avoid feeling suffocated when lying flat. Her medical background is significant for well-controlled type 2 diabetes mellitus and long-standing hypertension. She smoked cigarettes briefly in her twenties but quit over 30 years ago.

Current vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 162/94 mmHg, heart rate of 92/min, and respiratory rate of 22/min. Pulse oximetry displays 94% on ambient air.

During the physical examination, the physician observes distended jugular veins when the patient is seated at a 45-degree angle. Auscultation of the posterior lung fields reveals prominent bilateral basilar crackles. Symmetrical, pitting edema is present in both ankles.

A point-of-care chest radiograph demonstrates an enlarged cardiac silhouette and bilateral pulmonary vascular congestion. Laboratory studies, including a complete blood count, basic metabolic panel, and a thyroid-stimulating hormone (TSH) level of 1.8 mU/L, are within normal limits.

What is the most appropriate initial pharmacologic therapy for this patient?

A 74-year-old woman arrives at the emergency department accompanied by her daughter. She complains of rapidly worsening shortness of breath and a cough producing pink, frothy sputum over the past 12 hours. She has a medical history significant for essential hypertension, diet-controlled type 2 diabetes mellitus, and a 45-pack-year smoking history. Her current daily medications are amlodipine and metformin.

Vital signs are as follows:
- Temperature: $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$)
- Blood pressure: $210/115 \text{ mmHg}$
- Pulse: $118/\text{min}$
- Respiratory rate: $30/\text{min}$
- Oxygen saturation: $84\%$ on room air

Physical examination reveals a somnolent patient in severe respiratory distress, using accessory muscles of respiration. Jugular venous distention is prominent when the patient is seated upright. Lung auscultation reveals diffuse expiratory wheezes and coarse crackles extending from the bases to the mid-lung fields bilaterally. Cardiac auscultation demonstrates tachycardia, a regular rhythm, and a loud third heart sound (S3). Bilateral 2+ pitting edema is noted in the lower extremities.

Laboratory and arterial blood gas studies on room air reveal the following:
- Leukocyte count: $8,200/\text{mm}^3$
- Serum creatinine: $1.3 \text{ mg/dL}$
- Thyroid-stimulating hormone (TSH): $1.2 \,\mu\text{U/mL}$ (Normal: $0.5 - 5.0 \,\mu\text{U/mL}$)
- Free T4: $0.7 \text{ ng/dL}$ (Normal: $0.9 - 1.7 \text{ ng/dL}$)
- pH: $7.22$
- PaCO $_2$: $70 \text{ mmHg}$
- PaO $_2$: $50 \text{ mmHg}$
- HCO $_3^-$: $27 \text{ mEq/L}$

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

Emergency medical responders bring a $53$-year-old male to the emergency department due to severe, acute-onset respiratory distress. The patient's spouse reports he has been unable to sleep lying flat for the past two nights and has been coughing frequently. His medical history is significant for poorly controlled hypertension, type $2$ diabetes mellitus, and a $30$-pack-year smoking history. On arrival, he is sitting on the edge of the stretcher, diaphoretic, and using accessory muscles to breathe. Vital signs include a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $192/108\text{ mmHg}$, heart rate of $118/\text{min}$, and respiratory rate of $30/\text{min}$. Pulse oximetry shows an oxygen saturation of $84\%$ on room air. Physical examination reveals prominent jugular venous distention measuring $10\text{ cm H}_2\text{O}$ above the sternal angle. Auscultation of the lungs reveals diffuse expiratory wheezes and scattered crackles in the lower two-thirds of both lung fields. A bedside electrocardiogram demonstrates sinus tachycardia with left ventricular hypertrophy but no acute ST-segment changes. Which of the following is the most appropriate initial step in management?

An independent $54$-year-old woman is evaluated at a walk-in medical center after experiencing one week of escalating breathlessness. She mentions a newly developed, irritating cough that worsens when she attempts to sleep in her bed, prompting her to sleep propped up in a living room chair. The patient has a known history of essential hypertension and has smoked a pack of cigarettes daily for thirty years. Her vitals indicate a blood pressure of $172/96\text{ mmHg}$, a pulse of $108\text{/min}$, and respirations of $24\text{/min}$. Oxygen saturation reads $92\%$ while breathing ambient air. Physical examination reveals distended neck veins when she is seated upright. Auscultating her back reveals widespread crackles at both lung bases that persist despite directed coughing. Cardiac examination is notable for a rapid rate with a clearly audible $S_3$ gallop. Pressing on the skin of her lower legs leaves noticeable indentations bilaterally. Which of the following is the most appropriate initial pharmacologic intervention to relieve this patient's current respiratory symptoms?

During rounds in the intensive care unit, the telemetry alarm sounds for a 55-year-old female patient who was admitted for atypical chest pain. Upon entering the room, the medical team finds her unresponsive, apneic, and without a palpable pulse. The bedside monitor reveals chaotic, highly irregular waveform deflections of varying amplitudes with no discernible P waves, QRS complexes, or T waves. A manual defibrillator is immediately available at the bedside. Assuming her rhythm remains refractory to all interventions, arrange the following management steps in the correct chronological sequence according to the standard adult Advanced Cardiac Life Support (ACLS) algorithm.

Accompanied by her husband, a $62$-year-old woman arrives at the emergency department experiencing acute-onset breathlessness and a persistent cough. Her symptoms began rapidly over the past $4$ hours. She has a medical history notable for type $2$ diabetes mellitus and refractory major depressive disorder. Her daily medications include metformin and phenelzine. Three days ago, she developed a mild upper respiratory tract infection and began taking an over-the-counter oral decongestant containing pseudoephedrine.

On arrival, the patient is visibly distressed, diaphoretic, and speaking in short phrases. Her temperature is $37.0^{\circ}\mathrm{C}$ ($98.6^{\circ}\mathrm{F}$), blood pressure is $218/116$ mmHg, pulse is $114$/min, and respiratory rate is $26$/min. Pulse oximetry demonstrates an oxygen saturation of $89\%$ on room air. Physical examination reveals prominent jugular venous distention. Cardiac auscultation shows a regular tachycardia with a loud $S_4$ gallop and no discernible murmurs. Pulmonary auscultation reveals diffuse, fine inspiratory crackles bilaterally, extending up to the mid-lung fields. Bilateral trace pedal edema is present.

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

A 68-year-old man presents to the emergency department with acute onset of severe shortness of breath that awoke him from sleep. He has a history of hypertension, type 2 diabetes mellitus, and a 40-pack-year smoking history. His temperature is 37.1°C, blood pressure is 165/95 mmHg, pulse is 110/min, and respirations are 24/min. Pulse oximetry shows 88% on room air. Physical examination reveals jugular venous distention and bilateral pitting edema to the knees. The physician is evaluating the patient for acute decompensated heart failure versus an exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following additional findings would most specifically confirm acute decompensated heart failure in this patient?

A 72-year-old man is brought to the emergency department due to severe, worsening shortness of breath for the past 24 hours. He reports waking up in the middle of the night gasping for air and can only sleep propped up on three pillows. His medical history includes a 40-pack-year smoking history, type 2 diabetes mellitus, and hypertension. He was evaluated at an urgent care clinic three days ago for a mild cough; a sputum culture from that visit has finalized, growing normal respiratory flora with *Streptococcus pneumoniae* that is susceptible to penicillin and amoxicillin.

In the emergency department, his temperature is 37.1°C (98.8°F), blood pressure is 165/95 mmHg, heart rate is 112/min, and respiratory rate is 26/min. Pulse oximetry shows 88% on room air. Physical examination reveals elevated jugular venous pressure, bilateral basilar lung crackles, and diffuse expiratory wheezes. Cardiac auscultation demonstrates a normal $S_1$ and $S_2$ with an $S_3$ gallop.

Laboratory and diagnostic evaluation shows:

Arterial blood gas on room air:

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

A 72-year-old man is brought to the emergency department for severe, worsening shortness of breath that began 6 hours ago. The patient has a history of essential hypertension, type 2 diabetes mellitus, and a 40-pack-year smoking history. He reports that his breathing became significantly worse shortly after he laid down to sleep. Current medications include metformin, lisinopril, and amlodipine. His temperature is 37.1°C (98.8°F), blood pressure is 172/96 mmHg, pulse is 112/min and regular, and respiratory rate is 28/min. Pulse oximetry shows an oxygen saturation of 88% on room air.

Physical examination reveals a patient in moderate respiratory distress, using accessory muscles of respiration. Jugular venous pulsation is visible 9 cm above the sternal angle. Chest auscultation reveals diffuse expiratory wheezes and bibasilar crackles extending halfway up the lung fields. Cardiac examination reveals a regular tachycardia with a prominent third heart sound (S3). Bilateral 2+ pitting edema is present in the lower extremities.

Arterial blood gas on room air reveals:
pH: $7.28$
$pCO_2$: $56 \text{ mmHg}$
$pO_2$: $54 \text{ mmHg}$
$HCO_3^-$: $25 \text{ mEq/L}$

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

Match the classic auscultatory physical exam findings described below with the most likely underlying valvular pathology.

Match the following classic auscultatory and physical exam findings with their most likely underlying structural heart disease.

A 60-year-old man suddenly collapses while walking in the hospital lobby. He is found to be unresponsive, pulseless, and apneic. Bystanders immediately begin high-quality chest compressions. An automated external defibrillator (AED) is attached, and the rhythm monitor displays ventricular fibrillation. Arrange the following subsequent interventions in the correct chronological order according to standard Advanced Cardiovascular Life Support (ACLS) guidelines.

A 66-year-old man presents to the emergency department with the sudden onset of severe, tearing chest pain that radiates to his back. He appears diaphoretic and in severe distress. Blood pressure is 188/112 mm Hg in the right arm and 156/94 mm Hg in the left arm. Pulse is 112/min and bounding. Cardiac auscultation reveals a new decrescendo diastolic murmur at the right upper sternal border. An electrocardiogram shows sinus tachycardia with no ST-segment or T-wave changes. Suspecting an acute aortic syndrome, the physician prepares to manage the patient.

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

Emergency medical services bring a 65-year-old male to the resuscitation bay following the sudden onset of profound shortness of breath and altered mentation. The patient's wife states these symptoms began abruptly one hour ago while he was watching television. His medical history is notable for severe chronic obstructive pulmonary disease (COPD) managed with home oxygen therapy. Four days ago, he suffered an inferior ST-segment elevation myocardial infarction and was treated with percutaneous coronary intervention of the right coronary artery.

On physical examination, the patient is obtunded, diaphoretic, and using accessory muscles of respiration. Jugular venous pulsations are visible up to 11 cm $\text{H}_2\text{O}$. Auscultation of the chest reveals widespread coarse crackles and prolonged expiratory wheezing. Cardiac auscultation is significant for a hyperdynamic precordium and a new, loud, grade 4/6 holosystolic murmur heard loudest at the apex that radiates to the left axilla.

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

A 72-year-old woman is brought to the emergency department due to severe, acute-onset shortness of breath. She has a history of essential hypertension, type 2 diabetes mellitus, severe obesity (BMI $44 \text{ kg/m}^2$), and a 40-pack-year smoking history.

On arrival, her blood pressure is $182/105 \text{ mmHg}$, heart rate is $115\text{/min}$, and respiratory rate is $28\text{/min}$. Oxygen saturation is $86\%$ on room air.

Physical examination shows a patient in severe respiratory distress, using accessory muscles. Lung auscultation reveals diffuse expiratory wheezing with a markedly prolonged expiratory phase. No crackles are auscultated. Heart sounds are distant; no gallops are appreciated. Jugular venous pressure cannot be assessed due to body habitus.

Laboratory studies show a B-type natriuretic peptide (BNP) level of $210 \text{ pg/mL}$ (normal $<100 \text{ pg/mL}$).

Arterial blood gas analysis on room air shows:

A chest radiograph demonstrates hyperinflated lung fields, cardiomegaly, and prominent upper lobe vessels, without distinct alveolar infiltrates.

The patient receives sublingual nitroglycerin and intravenous furosemide, which leads to a dramatic resolution of her wheezing and dyspnea within one hour.

Which of the following best explains the relatively modest elevation of the B-type natriuretic peptide level in this patient despite the severity of her acute presentation?

A 72-year-old man is evaluated in the emergency department for severe, worsening shortness of breath that began two days ago. He reports waking up in the middle of the night gasping for air. His medical history includes ischemic heart disease, hypertension, and a 40-pack-year smoking history. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 165/95 mmHg, pulse of 108/min, and respiratory rate of 24/min. Pulse oximetry is 90% on room air. The physician suspects acute decompensated heart failure rather than a chronic obstructive pulmonary disease exacerbation. Which of the following physical examination findings is most specific for confirming a cardiac etiology for this patient's dyspnea?

During morning rounds on the surgical ward, a physician evaluates a 74-year-old male who developed progressive respiratory distress overnight. The patient was admitted 48 hours ago and underwent an elective total knee arthroplasty. He received 3 liters of intravenous crystalloid during the perioperative period. His past medical history includes hypertension, diet-controlled type 2 diabetes mellitus, and a 45-pack-year smoking history. Vital signs show a temperature of $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure of $172/96\text{ mmHg}$, heart rate of $108/\text{min}$, and respiratory rate of $26/\text{min}$. Pulse oximetry is $88\%$ on room air. On physical examination, the patient is sitting upright and using accessory muscles of respiration. Lung auscultation reveals diffuse expiratory wheezes and bilateral crackles extending to the mid-lung fields. The jugular veins are distended to $9\text{ cm H}_2\text{O}$ above the sternal angle. Cardiac examination demonstrates a regular, rapid rhythm with a distinct third heart sound (S3). Lower extremities show 1+ pitting edema bilaterally, which the patient states is unchanged from his preoperative baseline. Which of the following is the most appropriate next step in the management of this patient?

A $64$-year-old man with a history of hypertension, hyperlipidemia, and a $45$-pack-year smoking history presents to the primary care clinic with a $3$-month history of a cramping ache in his left calf. The pain reliably occurs after walking approximately two city blocks and resolves completely with $5$ minutes of rest. He has no leg pain at rest and no history of foot ulcers. His blood pressure is $142/86$ mmHg, and his pulse is $76$/min. Physical examination reveals thinning of the skin and loss of hair on the distal lower extremities bilaterally. The dorsalis pedis and posterior tibial pulses are faintly palpable bilaterally.

Arrange the following management steps in the most appropriate chronological sequence for this patient, from the initial diagnostic step to the last-resort intervention.

A 72-year-old woman is brought to the emergency department after a syncopal episode. She is currently conscious but complains of severe dizziness and chest pressure. Her blood pressure is 80/50 mm Hg, and her heart rate is 35/min. Arrange the following management steps in the most appropriate chronological sequence according to standard Advanced Cardiovascular Life Support (ACLS) guidelines for symptomatic bradycardia.