Cardiovascular System

A 62-year-old man arrives at the emergency department reporting the abrupt onset of severe, tearing chest pain radiating to his interscapular region. He appears diaphoretic and anxious. Vital signs show a heart rate of 118/min and blood pressure of 215/115 mm Hg in the right arm and 180/100 mm Hg in the left arm. Neurologic examination is unremarkable. Cardiac auscultation reveals an early diastolic decrescendo murmur at the right upper sternal border. Electrocardiogram demonstrates sinus tachycardia and criteria for left ventricular hypertrophy but no acute ischemic changes. Arrange the following interventions in the most appropriate chronological sequence for the management of this patient.

A $31$-year-old woman, G1P0, at $26$ weeks gestation is brought to the emergency department due to acute-onset severe shortness of breath, palpitations, and an episode of coughing up blood-tinged sputum. Her symptoms began abruptly $2$ hours ago. Over the past two months, she has experienced progressive fatigue and mild exertional dyspnea, which she attributed to her pregnancy. She emigrated from Southeast Asia five years ago and has not had consistent medical care. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $108/68$ mmHg, heart rate is $145$/min and irregularly irregular, respiratory rate is $28$/min, and oxygen saturation is $89\%$ on room air. Jugular venous pressure is elevated. The apical impulse is not displaced. Cardiac auscultation reveals a loud first heart sound, an early diastolic high-frequency sound, and a low-pitched mid-diastolic rumble at the apex. Bilateral fine crackles are heard in the lower two-thirds of the lung fields.

Laboratory results are as follows:
- Hemoglobin: $11.2$ g/dL
- Leukocyte count: $10,500$/mm $^3$
- Thyroid-stimulating hormone (TSH): $0.3$ mIU/L
- Free T4: $1.2$ ng/dL

Electrocardiography shows absent P waves, irregularly irregular R-R intervals, and right axis deviation. Which of the following is the most appropriate initial pharmacological intervention for this patient?

A 42-year-old man presents to the emergency department complaining of sharp, severe chest pain that began yesterday. He states that the pain is significantly worse when he breathes deeply or lies flat on his back, but it improves when he sits up and leans forward. He reports having had a mild upper respiratory infection with a sore throat one week ago. His temperature is 37.6°C (99.7°F), blood pressure is 120/80 mm Hg, heart rate is 95/min, respiratory rate is 16/min, and oxygen saturation is 99% on room air. Auscultation of the chest reveals a high-pitched, scratchy, three-component sound heard best at the left lower sternal border. An electrocardiogram (ECG) is obtained and shows diffuse, concave-upward ST-segment elevations and PR-segment depressions across multiple leads. Which of the following is the most appropriate initial treatment for this patient?

A $62$-year-old man is evaluated in the emergency department for worsening shortness of breath, lightheadedness, and profound fatigue over the past $3$ days. He has a history of advanced non-small cell lung cancer. His temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $88/70 \text{ mm Hg}$, pulse is $120/\text{min}$, and respirations are $24/\text{min}$. Pulse oximetry shows $94\%$ on room air. The patient appears dyspneic and anxious. Physical examination reveals jugular venous distention up to the angle of the mandible while sitting upright. Lungs are clear to auscultation bilaterally. Cardiac auscultation reveals distant heart sounds and tachycardia without murmurs. His systolic blood pressure drops by $15 \text{ mm Hg}$ during inspiration. Extremities are cool to the touch with faint peripheral pulses. An electrocardiogram displays sinus tachycardia with low voltage QRS complexes and beat-to-beat variation in the QRS axis. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old man is brought to the emergency department by emergency medical services due to severe, acute-onset shortness of breath and chest tightness that awoke him from sleep 1 hour ago. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of 35%, chronic obstructive pulmonary disease, hypertension, and erectile dysfunction. His current medications include aspirin, lisinopril, carvedilol, tiotropium, and sildenafil. He reports taking a dose of sildenafil 10 hours ago. The patient is diaphoretic and in severe respiratory distress, struggling to speak in full sentences. His temperature is 37.1°C (98.8°F), blood pressure is 210/115 mmHg, pulse is 115/min, and respiratory rate is 32/min with an oxygen saturation of 84% on room air. Physical examination reveals jugular venous distension 12 cm above the sternal angle. Cardiac auscultation reveals a regular tachycardia with a prominent S3 gallop. Lung auscultation reveals diffuse bilateral expiratory wheezes and crackles at the lung bases. Electrocardiogram shows sinus tachycardia with left ventricular hypertrophy and non-specific ST-segment changes. Which of the following is the most appropriate next step in management?

A 58-year-old man collapses in the hospital lobby. A nearby physician confirms he is unresponsive, apneic, and lacks a palpable carotid pulse. A resuscitation team arrives immediately with a crash cart, and the initial cardiac monitor displays coarse ventricular fibrillation. Arrange the following interventions in the correct chronological sequence according to standard Advanced Cardiac Life Support (ACLS) guidelines for adult cardiac arrest.

A $31$-year-old woman, G $1$ P $0$ at $34$ weeks gestation, is brought to the emergency department after being involved in a high-speed motor vehicle collision. She complains of anterior chest pain and severe shortness of breath. Her blood pressure is $78/48$ mm Hg, heart rate is $135$ bpm, and respiratory rate is $26$/min. Pulse oximetry shows $93\%$ on room air. Physical examination reveals distended jugular veins and distant, muffled heart sounds. Breath sounds are equal bilaterally, but faint scattered wheezes are auscultated. The trachea is midline. Bedside focused assessment with sonography for trauma (FAST) demonstrates a large anechoic space surrounding the heart with right ventricular free wall inversion during diastole. There is no evidence of intraperitoneal fluid. Continuous fetal heart rate monitoring shows a baseline of $140$ bpm with moderate variability and no decelerations. Which of the following is the most appropriate next step in management for this patient?

An established clinic patient, who is 68 years old, presents for evaluation of bilateral leg swelling that has gradually worsened over the past 3 months. He additionally notes new-onset abdominal fullness and becoming breathless after walking short distances. The patient is oxygen-dependent due to a long-standing history of severe chronic obstructive pulmonary disease (COPD) and has previously smoked heavily for four decades. His temperature is 37.0°C (98.6°F), blood pressure is 135/85 mm Hg, and pulse is 88/min. Physical examination reveals markedly distended jugular veins, a palpable parasternal heave, and 3+ pitting edema of the lower extremities bilaterally. Cardiac auscultation reveals a holosystolic murmur at the left lower sternal border that increases in intensity with inspiration. Breath sounds are decreased bilaterally with a prolonged expiratory phase, but no crackles are heard. Which of the following is the most likely primary mechanism for this patient's current presentation?

Match each clinical presentation and characteristic physical examination finding with the most likely underlying valvular pathology.

A 72-year-old woman is brought to the emergency department at 3:00 AM due to the sudden onset of severe shortness of breath and wheezing that awoke her from sleep. She has a history of essential hypertension, type 2 diabetes mellitus, and a 35-pack-year smoking history. Current medications include amlodipine and metformin. Her blood pressure is 170/95 mm Hg, pulse is 92/min, and respirations are 24/min. Pulse oximetry shows 90% on room air. Physical examination reveals diffuse bilateral expiratory wheezing and a prolonged expiratory phase. Jugular venous pulsation is estimated at 9 cm H₂O. Cardiac auscultation reveals a regular rate and rhythm with a prominent S4 gallop; no murmurs are appreciated. Trace bilateral lower extremity edema is present. An electrocardiogram shows normal sinus rhythm with voltage criteria for left ventricular hypertrophy. A chest radiograph reveals a slightly enlarged cardiac silhouette but no focal consolidation or pleural effusion. The patient is administered continuous nebulized albuterol and intravenous methylprednisolone for a presumed chronic obstructive pulmonary disease exacerbation. One hour later, her dyspnea acutely worsens. Repeat vital signs show a blood pressure of 120/70 mm Hg and a pulse of 128/min. Repeat lung auscultation now reveals prominent bibasilar crackles extending to the mid-lung fields. Which of the following pathophysiologic mechanisms best explains this patient's acute clinical deterioration?

A 58-year-old individual undergoing maintenance hemodialysis is admitted to the hospital due to progressive shortness of breath, orthopnea, and generalized fatigue over the past month. The patient has a history of type 2 diabetes mellitus and underwent creation of a left brachiocephalic arteriovenous fistula six months ago. Current medications include sevelamer, amlodipine, and erythropoietin. Vital signs reveal a blood pressure of $165/55$ mmHg, a pulse of $110$/min with bounding peripheral pulses, and a respiratory rate of $22$/min. Oxygen saturation is $93\%$ on ambient air. Physical examination demonstrates distended jugular veins up to $9$ cm $H_2O$. Auscultation of the lungs reveals bilateral basilar crackles and scattered expiratory wheezes. Cardiac examination shows a hyperdynamic precordium, a soft systolic ejection murmur at the left upper sternal border, and an audible S3 gallop. The left arm exhibits a very prominent thrill and a continuous bruit over the access site. Echocardiography demonstrates a left ventricular ejection fraction of $68\%$, biatrial enlargement, and a dilated left ventricle. Which of the following best describes the primary underlying hemodynamic derangement responsible for this patient's current symptoms?

A 68-year-old man presents to the urgent care clinic with a 2-day history of progressively worsening shortness of breath and cough. He states that he is having to work much harder to breathe than usual. His past medical history is significant for a myocardial infarction 3 years ago and chronic obstructive pulmonary disease (COPD) managed with an inhaled long-acting bronchodilator. He has a 40-pack-year smoking history. Temperature is 37.0°C (98.6°F), blood pressure is 152/90 mmHg, pulse is 108/min, and respiratory rate is 26/min. Oxygen saturation is 89% on room air. Lung auscultation reveals diffuse expiratory wheezes and scattered basilar crackles. Cardiac examination is difficult to hear clearly due to loud breath sounds, and the neck veins are not easily visible due to his body habitus. Which of the following is the most appropriate next diagnostic test to determine whether his symptoms are primarily due to acute decompensated heart failure rather than a COPD exacerbation?

Correlate each distinct clinical vignette describing a cardiovascular emergency or structural abnormality with its exact pathophysiological mechanism or primary hemodynamic derangement.

An emergency response team brings a 59-year-old woman to the resuscitation bay after she experienced a sudden onset of profound weakness and severe breathlessness at home. Her past medical history is significant for advanced non-small cell lung cancer and severe chronic obstructive pulmonary disease. On arrival, her blood pressure is 82/54 mm Hg, heart rate is 124/min, and respiratory rate is 26/min. Oxygen saturation is 94% on 2 L/min via nasal cannula. Physical examination reveals prominent jugular venous distention. The lung fields have scattered end-expiratory wheezes, but no crackles are heard. Cardiac auscultation demonstrates distant, muffled heart sounds. The patient's radial pulse is weak, and its amplitude noticeably diminishes during inspiration. Which of the following is the most appropriate next step in the management of this patient?

A 75-year-old man presents to the emergency department with acute-onset, severe dyspnea that woke him from sleep. He has a history of a myocardial infarction 5 years ago and a 45-pack-year smoking history. His blood pressure is 165/95 mmHg, heart rate is 112/min, and respiratory rate is 28/min. Pulse oximetry is 88% on room air. He is visibly distressed, sitting on the edge of the stretcher, and coughing up pink, frothy sputum. Pulmonary auscultation reveals diffuse bilateral wheezes and scattered crackles. Which of the following physical examination findings would most strongly support a primary cardiac etiology for this patient's acute respiratory distress over a primary pulmonary exacerbation?

Paramedics bring a 72-year-old man to the emergency department due to a 1-day history of severe dyspnea and increasing somnolence. His medical history includes severe chronic obstructive pulmonary disease (COPD) requiring continuous home oxygen, heart failure with a left ventricular ejection fraction of $35\%$, and essential hypertension. Upon arrival, his temperature is $37.1^\circ$ C ($98.8^\circ$ F), blood pressure is $165/95$ mm Hg, heart rate is $118$/min, and respiratory rate is $28$/min. Oxygen saturation is $84\%$ on his baseline $2$ L/min via nasal cannula. He is lethargic but arouses to loud verbal stimuli. Physical examination reveals an elevated jugular venous pressure of $13$ cm $H_2O$. Lung auscultation demonstrates diffuse, bilateral expiratory wheezing and prominent bibasilar fine crackles. Cardiac auscultation reveals a regular tachycardia with a distinct third heart sound ($S_3$). There is $2+$ bilateral pitting edema of the lower extremities. Laboratory studies show a leukocyte count of $8,500/mm^3$. An arterial blood gas analysis obtained on $2$ L/min of oxygen reveals:

$pH$: $7.22$
$PaCO_2$: $72$ mm Hg
$PaO_2$: $52$ mm Hg
$HCO_3^-$: $30$ mEq/L

A trial of noninvasive positive pressure ventilation (NIPPV) is immediately initiated. Which of the following is the most appropriate additional next step in the management of this patient?

A 34-year-old man with a history of intravenous drug use presents to the emergency department with a 4-day history of high fever, chills, and profound fatigue. His temperature is 39.2°C (102.6°F), blood pressure is 110/65 mm Hg, and heart rate is 112/min. Physical examination reveals a new holosystolic murmur at the left lower sternal border that increases in intensity with inspiration, as well as painless, erythematous macules on his palms.

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

While rounding in the surgical intensive care unit, a physician is called to the bedside of a $72$-year-old male who has developed abrupt respiratory distress and confusion. The patient underwent an open right hemicolectomy for colon adenocarcinoma three days prior. Until this morning, his recovery was unremarkable. Current vital signs include a temperature of $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), heart rate of 134/min, respiratory rate of 28/min, and blood pressure of 82/48 mmHg. Pulse oximetry reveals an oxygen saturation of 85% on room air.

Physical examination shows profound diaphoresis and jugular venous distention visible up to the angle of the mandible while sitting at a 45-degree angle. The surgical incision appears clean and intact with no surrounding erythema. Pulmonary ausculation yields clear breath sounds bilaterally without wheezes or crackles. Cardiac auscultation reveals a loud pulmonic component of the second heart sound (P2) and an S3 gallop best heard at the lower left sternal border.

A 12-lead electrocardiogram displays sinus tachycardia with new T-wave inversions in leads V1 through V4 and a rightward shift of the QRS axis. Which of the following is the most appropriate next step in the management of this patient?

A 73-year-old woman is brought to the emergency department at 2:00 AM by ambulance due to severe, worsening shortness of breath. She reports waking up abruptly gasping for air and feeling a tight sensation in her chest. Her medical history includes type 2 diabetes mellitus, hypertension, hyperlipidemia, and a 45-pack-year smoking history. She currently smokes half a pack of cigarettes daily. Temperature is 36.8°C (98.2°F), blood pressure is 178/102 mm Hg, pulse is 114/min, and respirations are 28/min. Pulse oximetry is 85% on room air. The patient is sitting upright on the edge of the stretcher, diaphoretic, and using accessory muscles of respiration. Physical examination reveals a jugular venous pressure estimated at 11 cm $H_2O$. Lung auscultation demonstrates diffuse expiratory wheezes and crackles halfway up both posterior lung fields. Cardiac auscultation reveals a regular tachycardia and a prominent third heart sound ($S_3$). The bilateral lower extremities exhibit 2+ pitting edema extending to the shins. Electrocardiogram shows sinus tachycardia and left ventricular hypertrophy. Which of the following is the most appropriate initial pharmacological management for this patient?

A 65-year-old woman is evaluated in the emergency department due to a two-day history of progressively worsening shortness of breath, a cough productive of yellow sputum, and a sensation of a racing heartbeat. Her medical history includes chronic obstructive pulmonary disease (COPD) and essential hypertension. Her daily home medications include an inhaled long-acting muscarinic antagonist and a low-dose thiazide diuretic. Vital signs show a temperature of 37.5°C (99.5°F), blood pressure of 132/84 mmHg, pulse of 128/min, and respiratory rate of 24/min. Pulse oximetry on room air is 88%. Physical examination reveals a prolonged expiratory phase with diffuse bilateral expiratory wheezing, but no inspiratory crackles. The jugular venous pressure is 8 cm H2O. Cardiac auscultation reveals an irregularly irregular rhythm with a loud P2, but no S3 gallop or murmurs are appreciated. Trace bilateral lower extremity edema is present. An electrocardiogram demonstrates a narrow QRS complex tachycardia with an irregular R-R interval, varying PR intervals, and three distinct P-wave morphologies in lead II. Which of the following is the most appropriate initial management for this patient's condition?