Cardiovascular System

Match each classic valvular abnormality to its most characteristic physical examination finding on cardiac auscultation.

A precise understanding of electrocardiographic lead localization is essential for identifying the specific coronary artery involved in an acute myocardial infarction. Match each presentation of characteristic 12-lead (and extended) ECG findings with the most likely culprit coronary artery and corresponding region of myocardial infarction.

A $74$-year-old woman presents to the acute care clinic with a $2$-day history of progressively worsening shortness of breath. She has a medical history significant for coronary artery disease, for which she underwent percutaneous coronary intervention $5$ years ago, and chronic obstructive pulmonary disease due to a $45$-pack-year smoking history. Over the past two nights, she has been unable to sleep flat in her bed, requiring multiple pillows to breathe comfortably. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $162/90\text{ mmHg}$, pulse is $115/\text{min}$, and respiratory rate is $28/\text{min}$. Pulse oximetry shows $88\%$ on room air. Physical examination reveals distended jugular veins when the patient is seated upright. Pulmonary auscultation reveals bilateral expiratory wheezes and dullness to percussion at the bases. Cardiac auscultation demonstrates a regular tachycardia and an early diastolic, low-frequency sound. Which of the following is the most appropriate initial therapy for this patient?

A 62-year-old man presents to the emergency department with a 3-day history of progressive exertional dyspnea, chest tightness, and a near-syncopal episode while climbing stairs. He has a 40-pack-year smoking history and does not take any daily medications. His temperature is 37.1°C (98.8°F), blood pressure is 112/68 mmHg, pulse is 88/min, and respirations are 20/min. Pulse oximetry shows 95% on room air. Pulmonary auscultation reveals mild, bilateral end-expiratory wheezing. Cardiac examination demonstrates a prominent apical impulse and a grade 3/6 harsh systolic crescendo-decrescendo murmur heard best at the left lower sternal border. An electrocardiogram shows left ventricular hypertrophy and deep, narrow Q waves in leads I, aVL, V5, and V6. Suspecting an acute exacerbation of chronic obstructive pulmonary disease and possible cardiac ischemia, the physician administers nebulized albuterol and sublingual nitroglycerin. Twenty minutes later, the patient becomes lightheaded and lethargic. His blood pressure drops to 76/42 mmHg, and his heart rate increases to 128/min. Cardiac auscultation now reveals a significantly louder and longer systolic murmur. Which of the following is the most appropriate next step in the management of this patient's acute deterioration?

A 34-year-old woman, G1P0, at 30 weeks gestation is brought to the emergency department due to the sudden onset of severe shortness of breath, orthopnea, and a cough productive of pink, frothy sputum. She recently emigrated from Southeast Asia and has not received routine prenatal care. Her vital signs are temperature 37.0°C (98.6°F), blood pressure 105/65 mm Hg, heart rate 138/min and irregularly irregular, and respiratory rate 32/min. Pulse oximetry shows 87% on room air.

Physical examination reveals a distressed woman using accessory muscles of respiration. Lung auscultation demonstrates diffuse bilateral crackles extending to the apices and prominent expiratory wheezes. Cardiac auscultation reveals a loud $S_1$, a high-frequency sound shortly after $S_2$, and a low-pitched, rumbling mid-diastolic murmur heard best at the cardiac apex.

Laboratory results show:
Hemoglobin: 10.8 g/dL
Leukocyte count: 8,500/mm $^3$

Arterial blood gas on room air:
pH: 7.51
$PaCO_2$: 26 mm Hg
$PaO_2$: 54 mm Hg
$HCO_3^-$: 20 mEq/L

Which of the following is the most important primary pathophysiologic mechanism precipitating this patient's acute respiratory failure?

Paramedics rush a 58-year-old man to the resuscitation bay after he experienced a sudden, agonizing, 'tearing' chest pain that radiated directly to his interscapular region. The patient is visibly distressed, diaphoretic, and clutching his chest. His spouse reports that he has a long history of medication nonadherence for hypertension. Initial vital signs reveal a temperature of 37.2°C (99.0°F), a right arm blood pressure of 220/125 mm Hg, a left arm blood pressure of 180/100 mm Hg, a heart rate of 124/min, and a respiratory rate of 24/min. Cardiac auscultation identifies a loud, early diastolic decrescendo murmur best heard at the right second intercostal space. A bedside portable chest radiograph displays significant widening of the superior mediastinum. Large-bore intravenous access is immediately established. Arrange the following critical interventions in the exact sequential order required for the optimal management of this patient, from immediate initial stabilization to definitive treatment.

A 68-year-old man presents to a rural clinic with severe substernal chest pain. He is diagnosed with an acute ST-segment elevation myocardial infarction (STEMI). Due to limited resources and transport delays, definitive revascularization is significantly delayed, allowing the infarction to follow its natural clinical course. Arrange the following electrocardiographic (ECG) changes in the typical chronological order in which they appear during the evolution of an untreated acute transmural myocardial infarction.

A $68$-year-old male is evaluated in the intensive care unit for abrupt-onset severe respiratory distress and hypotension. Four days ago, he was admitted with an acute ST-segment elevation myocardial infarction involving the inferior leads; he subsequently received a drug-eluting stent to the right coronary artery. His medical history includes hypertension and a $40$-pack-year smoking habit. Vital signs are temperature $36.9^\circ\text{C}$ ($98.4^\circ\text{F}$), blood pressure $82/54\text{ mm Hg}$, heart rate $118\text{/min}$, and respirations $28\text{/min}$. Oxygen saturation is $84\%$ on a non-rebreather mask. Physical examination reveals cool, diaphoretic extremities and elevated jugular venous pressure. Auscultation of the chest demonstrates bilateral crackles extending halfway up the lung fields with scattered expiratory wheezes. A new, loud holosystolic murmur is heard best at the cardiac apex with radiation to the left axilla. Which of the following is the most likely cause of this patient's current clinical deterioration?

Match the following classic arterial pulse abnormalities with their most likely underlying cardiovascular pathology.

A $72$-year-old man is brought to the emergency department by his daughter due to a $2$-day history of progressively worsening shortness of breath, a cough productive of yellow sputum, and palpitations. His medical history is significant for hypertension, hyperlipidemia, and chronic obstructive pulmonary disease (COPD). He has a $50$-pack-year smoking history. Current medications include inhaled tiotropium, inhaled fluticasone, and oral amlodipine. His temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $138/86$ mmHg, pulse is $134$/min and irregular, and respirations are $26$/min. Pulse oximetry is $87\%$ on room air. Physical examination reveals a barrel chest with prominent use of accessory muscles of respiration. Lung auscultation demonstrates a prolonged expiratory phase and diffuse wheezing bilaterally. There is no jugular venous distention or peripheral edema. An electrocardiogram reveals an irregular rhythm with narrow QRS complexes, absent flutter waves, and $3$ distinct P wave morphologies in lead II. Which of the following is the most appropriate initial management for this patient?

During a routine outpatient evaluation, a physician examines a patient with a long-standing history of severe chronic obstructive pulmonary disease. The patient reports a three-month history of progressive bilateral leg swelling and a noticeable decline in exercise tolerance. Vital signs are stable. On physical examination, the physician notes prominent jugular venous distention and a palpable parasternal heave. Auscultation reveals globally decreased breath sounds without inspiratory crackles. A subsequent point-of-care echocardiogram demonstrates marked right ventricular dilation alongside a completely normal left ventricular ejection fraction. Which of the following underlying pathophysiologic mechanisms most likely initiated this patient's cardiac findings?

A 62-year-old man collapses while walking in the hospital corridor. He is unresponsive, apneic, and has no palpable carotid pulse. A crash cart is immediately brought to the scene, and chest compressions are initiated. The cardiac monitor displays coarse ventricular fibrillation. Arrange the following critical resuscitation steps in the most appropriate chronological order according to standard advanced cardiovascular life support (ACLS) guidelines.

A 65-year-old man is brought to the emergency department by emergency medical services after collapsing at home. His wife reports that he had been complaining of palpitations and dizziness for the past several hours. He has a history of heart failure with reduced ejection fraction and atrial fibrillation, for which he takes carvedilol, sacubitril-valsartan, and amiodarone. Three days ago, he was evaluated at an urgent care clinic and prescribed oral ciprofloxacin for a suspected urinary tract infection. On arrival, the patient is minimally responsive. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $72/40\text{ mmHg}$, pulse is $185\text{/min}$, and respirations are $22\text{/min}$. Cardiopulmonary examination reveals cold, clammy extremities and faint distal pulses. Continuous cardiac monitoring displays a rapid, irregular, wide-complex tachycardia with cyclic alterations in the QRS axis amplitude, appearing to twist around the isoelectric line. What is the most appropriate initial step in the management of this patient?

A $72$-year-old man presents to the emergency department complaining of severe lightheadedness, generalized weakness, and near-syncope that started one hour ago. His blood pressure is $78/50$ mmHg, heart rate is $32$/min, and respiratory rate is $16$/min. Oxygen saturation is $96\%$ on room air. An electrocardiogram (ECG) reveals sinus bradycardia with a heart rate of $32$/min. The patient remains persistently hypotensive and symptomatic despite initial intravenous fluid resuscitation. Arrange the following interventions in the most appropriate chronological sequence for the management of this patient, from the most immediate initial step to definitive long-term therapy.

A 63-year-old woman is brought to the emergency department from an inpatient rehabilitation facility due to sudden-onset severe shortness of breath and lightheadedness. Two weeks ago, she underwent an uncomplicated right total hip arthroplasty. Her medical history includes chronic obstructive pulmonary disease, essential hypertension, and hypothyroidism. Upon arrival, her blood pressure is 76/45 mmHg, heart rate is 126/min, respiratory rate is 28/min, and oxygen saturation is 84% on room air. She appears diaphoretic, agitated, and is using accessory muscles of respiration. Physical examination reveals jugular venous distention up to the angle of the mandible while seated upright. Auscultation of the lungs demonstrates scattered expiratory wheezes. Cardiac examination shows a prominent right ventricular heave, a loud P2, and a grade 2/6 holosystolic murmur at the left lower sternal border. The right thigh and calf are moderately swollen and tender. An electrocardiogram shows sinus tachycardia, new-onset complete right bundle branch block, and T-wave inversions in leads V1 through V4. Laboratory studies show a serum troponin I of $0.8$ ng/mL (normal $<0.04$), thyroid-stimulating hormone of $1.2$ $\mu U/mL$ (normal $0.4-4.0$), and free T4 of $0.6$ ng/dL (normal $0.9-1.7$). Which of the following is the most appropriate next step in the management of this patient?

A 69-year-old male is transported to the acute care bay by paramedics following an abrupt onset of severe respiratory distress and profound diaphoresis that commenced one hour prior to arrival. His past medical history includes long-standing essential hypertension, type 2 diabetes mellitus, and a 40-pack-year smoking history. Upon arrival, he is extremely agitated, using accessory muscles of respiration, and cannot speak in full sentences.

Vital signs are temperature $36.8^\circ$ C ($98.2^\circ$ F), blood pressure $235/125$ mm Hg, pulse $122$/min, and respirations $38$/min. Oxygen saturation is $82\%$ on room air.

Physical examination reveals neck veins distended to the angle of the jaw while the patient is sitting upright. Lung auscultation demonstrates diffuse, high-pitched expiratory wheezes bilaterally with a significantly prolonged expiratory phase; no crackles are appreciated. Cardiac auscultation reveals a regular, rapid rhythm with a loud S2, though other heart sounds are obscured by the respiratory noise.

Arterial blood gas analysis on room air shows:
pH: $7.18$
PaCO $_2$: $65$ mm Hg
PaO $_2$: $48$ mm Hg
HCO $_3^-$: $24$ mEq/L

An electrocardiogram reveals sinus tachycardia with voltage criteria for left ventricular hypertrophy and secondary ST-segment repolarization abnormalities.

Which of the following is the most appropriate initial management step for this patient?

A 54-year-old man collapses in an airport terminal and is unresponsive. Bystanders immediately initiate cardiopulmonary resuscitation (CPR). Emergency medical services (EMS) arrive shortly after and confirm the patient is pulseless and apneic. The cardiac monitor displays coarse ventricular fibrillation. Arrange the following critical interventions in the correct chronological sequence for the management of this patient according to standard cardiac arrest algorithms.

Match the following valvular pathologies with their classic auscultatory findings on physical examination.

A 28-year-old woman presents to the clinic with an 8-month history of progressive exertional dyspnea, fatigue, and one episode of syncope while climbing stairs. She has no significant past medical history and takes no medications. Her blood pressure is 110/70 mm Hg, pulse is 88/min, and respirations are 16/min. Pulse oximetry shows 97% on room air. Physical examination reveals clear lungs, a prominent right ventricular heave, and a loud pulmonic component of the second heart sound. There is trace lower extremity edema. A transthoracic echocardiogram demonstrates right ventricular dilation, septal flattening during systole, and an estimated right ventricular systolic pressure of 55 mm Hg. The left ventricular size and systolic function are normal, with no significant valvular abnormalities. Pulmonary function testing and high-resolution computed tomography (HRCT) of the chest are unremarkable.

Arrange the following steps in the most appropriate sequential order for the continued diagnostic evaluation and management of this patient's condition.

A $70$-year-old woman presents to the emergency department with severe shortness of breath and wheezing that began $2$ hours ago. She has a history of poorly controlled hypertension and a $30$-pack-year smoking history. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $170/95\text{ mmHg}$, pulse is $112/\text{min}$, and oxygen saturation is $88\%$ on room air. Physical examination reveals distended jugular veins, a third heart sound (S3) on cardiac auscultation, and bilateral diffuse wheezing intermixed with bibasilar crackles. Which of the following is the most appropriate initial pharmacologic therapy for this patient?