Cardiovascular System

Match each clinical presentation and its associated physical examination findings with the most likely underlying structural or valvular cardiac pathology.

Match each patient's clinical presentation and dynamic auscultation findings to the most likely underlying structural or valvular pathology.

A previously healthy individual collapses while walking through the hospital cafeteria. Medical staff rapidly confirm the absence of a central pulse and normal breathing. A crash cart is brought to the scene, and the cardiac monitor displays coarse ventricular fibrillation. Arrange the following subsequent interventions in the correct chronological order according to standard Advanced Cardiovascular Life Support (ACLS) protocols for this specific presentation.

A 62-year-old man suddenly collapses while walking in the hospital corridor. He is unresponsive, pulseless, and apneic. A code blue is activated, and high-quality cardiopulmonary resuscitation (CPR) is immediately initiated. The crash cart arrives, and the defibrillator pads are applied. The cardiac monitor displays coarse ventricular fibrillation. Assuming the patient remains pulseless and the rhythm remains unchanged throughout the resuscitation, arrange the following management steps in the correct chronological sequence according to Advanced Cardiac Life Support (ACLS) guidelines.

Match each clinical presentation of a patient in circulatory collapse with the most likely corresponding invasive hemodynamic profile (pulmonary artery catheterization findings) expected upon initial evaluation.

A 72-year-old man is brought to the emergency department from an extended care facility due to progressively worsening shortness of breath, generalized weakness, and a nonproductive cough over the past $48$ hours. He tells the physician, "I just feel so tired and low lately, I can barely get out of bed." His medical history includes ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$, severe chronic obstructive pulmonary disease (COPD), bipolar disorder, and hypothyroidism. Three days ago, he underwent an uncomplicated open right inguinal hernia repair. His current medications include lisinopril, metoprolol succinate, tiotropium, and lithium.

Vital signs are temperature $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), pulse $118$/min and irregularly irregular, blood pressure $160/92$ mmHg, respiratory rate $26$/min, and oxygen saturation $89\%$ on room air.

Physical examination reveals a patient in mild respiratory distress. Jugular venous pressure is elevated to $11$ cm $\text{H}_2\text{O}$. Lung auscultation reveals bilateral basilar crackles and diffuse end-expiratory wheezing. Cardiac auscultation demonstrates an irregularly irregular rhythm without significant murmurs. The abdominal surgical incision is clean, dry, and intact with no surrounding erythema.

Laboratory results:
Brain natriuretic peptide (BNP): $950$ pg/mL
Thyroid-stimulating hormone (TSH): $0.2$ $\mu$ U/mL (normal: $0.5-5.0$)
Free thyroxine (T4): $0.7$ ng/dL (normal: $0.9-1.7$)

An electrocardiogram shows atrial fibrillation with a rapid ventricular response and no acute ST-segment changes. Which of the following is the most appropriate next step in management?

A $48$-year-old man is evaluated in the hospital for new-onset exertional dyspnea, fatigue, and lightheadedness over the past $24$ hours. He was admitted $6$ days ago for native aortic valve infective endocarditis caused by *Streptococcus mitis*. Blood cultures demonstrated that the organism is highly susceptible to penicillin, and he has been receiving targeted intravenous aqueous crystalline penicillin G. His temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $102/60 \text{ mm Hg}$, pulse is $42/\text{min}$, and respirations are $18/\text{min}$. Physical examination reveals a harsh, early diastolic decrescendo murmur at the left sternal border. The lungs are clear to auscultation. Electrocardiogram reveals sinus rhythm with a PR interval of $280 \text{ ms}$ (first-degree atrioventricular block) and a new left bundle branch block. Laboratory studies show a leukocyte count of $8,500/\text{mm}^3$, a thyroid-stimulating hormone (TSH) level of $0.2 \text{ \mu U/mL}$ (Normal: $0.4$-$4.0 \text{ \mu U/mL}$), and a free T4 of $0.7 \text{ ng/dL}$ (Normal: $0.9$-$2.4 \text{ ng/dL}$). The patient is currently lethargic and lacks medical decision-making capacity. His brother is at the bedside and demands that the medical team immediately switch the antibiotics to a "stronger" regimen, but the patient's advance directive legally appoints his wife, who is en route to the hospital, as his healthcare proxy. Which of the following is the most appropriate next step in the management of this patient?

Match each characteristic hemodynamic profile or physical examination finding with the most likely underlying cardiovascular pathology.

A $36$-year-old woman, G2P2, comes to the emergency department due to a $3$-day history of progressively worsening shortness of breath and an inability to lie flat. She delivered a healthy infant via an uncomplicated spontaneous vaginal delivery $3$ weeks ago. Her medical history is significant for mild asthma, which has been controlled without regular medications for the past five years. She takes no medications and does not use tobacco, alcohol, or illicit substances. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, heart rate is $112/\text{min}$, and respiratory rate is $24/\text{min}$. Pulse oximetry shows an oxygen saturation of $88\%$ on room air. Physical examination demonstrates jugular venous distension up to $9\text{ cm H}_2\text{O}$ above the sternal angle. Auscultation of the lungs reveals bilateral fine bibasilar crackles with scattered expiratory wheezes. Cardiac examination shows a regular, rapid rhythm, a prominent third heart sound ($S_3$), and a grade $2/6$ holosystolic murmur best heard at the apex. The lower extremities show $2+$ bilateral pitting edema. Which of the following is the most appropriate initial pharmacological management for this patient?

A 68-year-old man comes to the clinic due to a 6-week history of progressively worsening shortness of breath and a dry, nonproductive cough. He has a history of hypertension, type 2 diabetes mellitus, and symptomatic paroxysmal atrial fibrillation. His medications include amiodarone, metoprolol, apixaban, and lisinopril. The patient has never smoked. His temperature is 37.1°C (98.8°F), blood pressure is 128/82 mm Hg, pulse is 68/min, and respirations are 22/min. Pulse oximetry shows 91% on room air. Physical examination reveals fine, bilateral inspiratory crackles at the lung bases. Cardiac examination shows a regular rate and rhythm with normal S1 and S2; there are no murmurs or gallops. Jugular venous pressure is 6 cm $H_2O$. There is no lower extremity edema. Laboratory studies show a normal leukocyte count and a brain natriuretic peptide (BNP) level of 65 pg/mL. Thyroid-stimulating hormone (TSH) is 5.8 $\mu$ U/mL (normal: 0.4-4.0 $\mu$ U/mL) and free T4 is 1.1 ng/dL (normal: 0.9-1.7 ng/dL). Chest radiography demonstrates diffuse, bilateral interstitial opacities. Electrocardiography shows normal sinus rhythm. Which of the following is the most appropriate next step in management?

During a cardiology rotation, a medical student is evaluating several patients with distinct heart murmurs. The attending physician emphasizes the importance of dynamic auscultatory maneuvers in differentiating structural cardiac defects based on how alterations in preload and afterload affect intracardiac hemodynamics. Correlate each patient's specific auscultatory response with the most likely underlying cardiovascular condition.

A 64-year-old man is brought to the emergency department due to sudden-onset, severe, "tearing" chest pain that radiates to his back between the shoulder blades. His blood pressure is 210/115 mm Hg in the right arm and 170/95 mm Hg in the left arm. His pulse is 115/min. Physical examination reveals an early diastolic decrescendo murmur at the right upper sternal border. Electrocardiogram shows sinus tachycardia and voltage criteria for left ventricular hypertrophy without acute ischemic changes. Chest x-ray reveals a widened mediastinum. A presumptive diagnosis of acute aortic dissection is made. Arrange the following steps in the most appropriate clinical sequence for managing this patient.

Match each clinical presentation following an acute ST-segment elevation myocardial infarction with the most likely underlying structural or inflammatory complication.

A $69$-year-old man comes to the clinic with progressively worsening lower extremity edema, fatigue, and exertional dyspnea over the last three months. He has a $50$-pack-year smoking history and was diagnosed with severe chronic obstructive pulmonary disease (COPD) four years ago. He is compliant with his long-acting muscarinic antagonist and beta-agonist inhalers. Vital signs show a blood pressure of $132/84\text{ mmHg}$, pulse of $88\text{/min}$, and respirations of $18\text{/min}$. Oxygen saturation is $91\%$ on room air. Physical examination shows a barrel-shaped chest with decreased breath sounds bilaterally. The jugular venous pressure is elevated at $12\text{ cm H}_2\text{O}$. Heart sounds are distant, but a regular rhythm is appreciated. Abdominal examination shows hepatomegaly. There is $2+$ pitting edema extending to the knees bilaterally. The physician is trying to determine if the patient has developed concurrent left ventricular failure or if his symptoms are solely due to cor pulmonale from his severe COPD. Which of the following findings on further evaluation would most strongly indicate the presence of concurrent left-sided heart failure rather than isolated cor pulmonale?

Paramedics transport a $58$-year-old male to the emergency department following the acute onset of unrelenting retrosternal chest pressure and profound diaphoresis that began $90$ minutes ago. On evaluation, his blood pressure is $82/52$ mmHg and his pulse is $52$/min. His respiratory rate is $16$/min and oxygen saturation is $96\%$ on room air. Physical examination demonstrates visibly distended neck veins while the patient is sitting at a $45^\circ$ angle. Auscultation reveals clear lung fields bilaterally without crackles or wheezing. Cardiac examination demonstrates a regular, slow rhythm without murmurs, rubs, or gallops. A 12-lead electrocardiogram obtained by triage staff demonstrates $3$-mm convex ST-segment elevations in leads II, III, and aVF, with reciprocal ST-segment depressions in leads I and aVL. In addition to antiplatelet therapy and preparation for immediate revascularization, which of the following is the most appropriate initial intervention to stabilize this patient's hemodynamics?

A $58$-year-old male patient is recovering in the cardiac intensive care unit following an anterior wall myocardial infarction. On hospital day $2$, the telemetry alarms sound. The nurse finds the patient unresponsive and apneic, with no palpable carotid pulse. The bedside cardiac monitor displays a regular, wide-complex tachycardia at a rate of $210/\text{min}$. Arrange the following resuscitation interventions in the most appropriate chronological sequence from first to last according to standard adult advanced cardiovascular life support (ACLS) algorithms.

Match the following classic electrocardiographic (ECG) findings with their most likely underlying cardiac structural pathology, inflammatory condition, or electrophysiological syndrome.

During an overnight shift in the emergency department, a $73$-year-old woman is evaluated for severe, acute-onset respiratory distress. She reports waking up abruptly with a choking sensation and an inability to catch her breath. Her medical history includes chronic obstructive pulmonary disease, hypertension, and type 2 diabetes mellitus. Her home medications include amlodipine, metformin, and a tiotropium inhaler. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $182/104\text{ mm Hg}$, pulse is $115\text{/min}$ and regular, and respirations are $28\text{/min}$. Pulse oximetry shows an oxygen saturation of $86\%$ on room air. The patient is visibly anxious, diaphoretic, and speaking in short phrases. Jugular venous pressure is estimated at $10\text{ cm H}_2\text{O}$. Chest auscultation reveals diffuse, bilateral expiratory wheezes and prominent fine crackles in the lower lung fields. Cardiac examination demonstrates a normal $S_1$ and $S_2$ with an audible $S_3$ gallop. Trace bilateral pitting edema is present at the ankles. Which of the following is the most appropriate initial pharmacotherapy for this patient?

An obtunded $71$-year-old man is evaluated in the emergency department for acute, severe dyspnea and altered mental status. He has a past medical history of ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$, severe chronic obstructive pulmonary disease, and type 2 diabetes mellitus. He was evaluated at an outpatient clinic two days ago for a mild cough; a sputum culture from that visit is now resulting, showing *Haemophilus influenzae* susceptible to amoxicillin. The patient is accompanied by his estranged wife and his brother. The brother provides a legally binding document designating him as the patient's healthcare proxy. The wife demands that the patient be placed on a mechanical ventilator immediately, while the brother requests that medical therapies be optimized first before considering intubation.

Vital signs include a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $82/55\text{ mm Hg}$, pulse of $118/\text{min}$, and respirations of $28/\text{min}$. Oxygen saturation is $88\%$ on room air. Physical examination reveals a somnolent but arousable patient. The extremities are cool and clammy with faint peripheral pulses. Jugular venous pressure is elevated to $13\text{ cm H}_2\text{O}$. Lung auscultation demonstrates diffuse, high-pitched expiratory wheezes bilaterally without crackles. Cardiac auscultation reveals distant heart sounds with a regular tachycardia.

Laboratory results are as follows:
Leukocyte count: $11,500/\mu\text{L}$
Lactic acid: $4.8\text{ mmol/L}$
Thyroid-stimulating hormone: $1.2\text{ }\mu\text{U/mL}$ (Normal: $0.4-4.0\text{ }\mu\text{U/mL}$)
Free T4: $0.6\text{ ng/dL}$ (Normal: $0.9-1.7\text{ ng/dL}$)

A chest radiograph reveals an enlarged cardiac silhouette with prominent upper lobe vasculature and no focal consolidations. Which of the following is the most appropriate next step in the management of this patient?

A $54$-year-old man is brought to the emergency department via ambulance after his wife found him lethargic at home. She reports that he has a medical history of hypertension, major depressive disorder, and hyperlipidemia. Empty bottles of metoprolol and hydrochlorothiazide were found near his bed. On arrival, the patient is minimally responsive. His temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), blood pressure is $70/40$ mmHg, pulse is $34$/min, and respiratory rate is $14$/min. The $12$-lead electrocardiogram demonstrates sinus bradycardia with a first-degree atrioventricular block and no acute ST-segment changes. Intravenous access is established, and a $1$-liter bolus of normal saline is rapidly infused with no improvement in hemodynamics.

Arrange the following subsequent interventions in the most appropriate chronological sequence for the emergency management of this patient's condition.