Cardiovascular System

A 45-year-old man with a history of intravenous drug use presents to the hospital with a 5-day history of severe chills, fatigue, and high fevers. On physical examination, his temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), heart rate is 112/min, and blood pressure is 118/76 mm Hg. Cardiac auscultation reveals a newly documented holosystolic murmur prominent at the lower left sternal border. Cutaneous examination demonstrates painful, violaceous nodules on the pads of his fingers. Suspecting acute infective endocarditis, arrange the following clinical management steps in the correct chronological sequence according to standard guidelines.

Emergency medical services transport a 61-year-old male to the resuscitation bay following the acute onset of heavy, retrosternal chest pressure, diaphoresis, and severe shortness of breath. The symptoms began approximately 90 minutes ago. His medical history includes type 2 diabetes mellitus and a 45-pack-year smoking history.

On arrival, his temperature is $37.4^{\circ}\text{C}$ ($99.3^{\circ}\text{F}$), blood pressure is $82/50$ mmHg, heart rate is $108$/min, and respiratory rate is $26$/min. Pulse oximetry is $91\%$ on room air.

Physical examination reveals prominent jugular venous distention with a positive Kussmaul sign. Chest auscultation yields faint, bilateral expiratory wheezes, but no crackles. Cardiac auscultation reveals a regular tachycardia, a right-sided $S_4$ gallop, and no murmurs.

A 12-lead electrocardiogram displays $3$-mm ST-segment elevations in leads II, III, and aVF, with reciprocal ST-segment depressions in leads I and aVL. Right-sided ECG leads show a $2$-mm ST-segment elevation in lead $V_4R$.

An arterial blood gas analysis on room air reveals:

The patient is immediately administered chewable aspirin and intravenous heparin.

Which of the following is the most appropriate initial step to address this patient's hemodynamic status prior to definitive reperfusion therapy?

A $68$-year-old man presents to the emergency department with worsening shortness of breath and nocturnal awakenings over the past $5$ days. He reports needing to sleep in a reclining chair to breathe comfortably and frequently wakes up gasping for air. The patient has a history of hypertension, type 2 diabetes mellitus, and a $40$-pack-year smoking history. He has tried using an over-the-counter bronchodilator inhaler without relief. Vital signs show a blood pressure of $165/95 \text{ mm Hg}$, pulse of $105\text{/min}$, and respirations of $22\text{/min}$. Pulse oximetry is $91\%$ on room air. On physical examination, the body mass index is $32 \text{ kg/m}^2$. The jugular venous pulse is visible $5 \text{ cm}$ above the sternal angle while seated at a $45^\circ$ angle. Lung auscultation reveals prolonged expiration, diffuse bilateral wheezes, and dullness to percussion at the lung bases. Cardiac examination reveals a regular tachycardia with a prominent early diastolic extra heart sound at the apex. Trace bilateral pitting edema is present at the ankles. Which of the following pathophysiologic processes best explains the primary cause of this patient's respiratory findings?

A 72-year-old woman comes to the outpatient clinic due to a 4-day history of progressively worsening shortness of breath. She also reports waking up multiple times at night feeling a sensation of suffocation, which is only relieved by sitting upright for several minutes. Her medical history includes long-standing hypertension, type 2 diabetes mellitus, and a 35-pack-year smoking history. Current medications include lisinopril, amlodipine, and metformin. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 162/94 mm Hg, pulse of 102/min, and respiratory rate of 22/min. Pulse oximetry is 92% on room air. Examination reveals elevated jugular venous pressure and pitting edema of the lower extremities up to the knees. Which of the following additional physical examination findings is most likely to be present in this patient?

A $68$-year-old man is evaluated for progressive shortness of breath, fatigue, and bilateral lower extremity swelling over the past $6$ months. He also reports numbness and tingling in both hands, for which he underwent bilateral carpal tunnel release surgery last year. Blood pressure is $110/70 \text{ mmHg}$, and pulse is $85 \text{ /min}$. Physical examination reveals elevated jugular venous pressure with prominent x and y descents, clear lungs, and $2+$ pitting edema in the lower extremities. An electrocardiogram shows low voltage in the limb leads. A transthoracic echocardiogram demonstrates severe left ventricular concentric thickening, a granular "sparkling" appearance of the myocardium, biatrial enlargement, and a preserved left ventricular ejection fraction of $60\%$. A diagnosis of cardiac amyloidosis is suspected.

Arrange the following diagnostic and management steps in the most appropriate chronological sequence for evaluating and treating this patient's condition.

A $54$-year-old woman arrives at the emergency department with severe, sudden-onset breathing difficulty that started one hour ago. The patient has a history of long-standing hypertension but has not taken her prescribed medications for several months.

On evaluation, she is sitting upright, diaphoretic, and in significant respiratory distress.

Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $220/115\text{ mm Hg}$, heart rate of $118/\text{min}$, and respiratory rate of $28/\text{min}$. Oxygen saturation is $88\%$ on room air.

Physical examination reveals prominent jugular venous distention. Pulmonary auscultation demonstrates bilateral crackles extending to the apices and widespread expiratory wheezing.

Cardiac auscultation reveals a regular tachycardia and a prominent fourth heart sound (S4). There is no peripheral edema.

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

Match each physical examination finding and its corresponding response to dynamic auscultatory maneuvers with the most likely underlying structural or valvular pathology.

A 34-year-old man with a history of intravenous opioid use disorder is hospitalized for a 1-week history of fever, chills, and pleuritic chest pain. On admission, multiple sets of blood cultures are drawn, and empiric intravenous vancomycin and cefepime are initiated. A transthoracic echocardiogram reveals a $1.4\text{-cm}$ mobile vegetation on the tricuspid valve with moderate tricuspid regurgitation. Two days later, all blood culture bottles grow *Staphylococcus aureus*. Susceptibility testing indicates the isolate is resistant to penicillin G, but susceptible to oxacillin, cefazolin, and vancomycin. The patient's medical record notes a history of a diffuse maculopapular rash after taking amoxicillin for a respiratory infection 5 years ago; he specifically denies any history of facial swelling, difficulty breathing, or anaphylaxis associated with medications. His temperature is currently $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $122/76\text{ mm Hg}$, and heart rate is $82/\text{min}$. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A patient with a fifty-pack-year smoking history and severe chronic obstructive pulmonary disease comes to the clinic for a routine follow-up. He is seventy-two years old and reports progressively worsening fatigue, bilateral leg swelling, and right upper quadrant abdominal discomfort over the past few months. His current medications include a long-acting muscarinic antagonist and an inhaled corticosteroid. Vital signs show a respiratory rate of $22$/min and an oxygen saturation of $87\%$ on room air. Physical examination reveals elevated jugular venous pressure, a right ventricular heave, and $2+$ pitting edema of the lower extremities up to the knees. Auscultation of the heart reveals a loud $P_2$. Lung auscultation shows decreased breath sounds globally without wheezes. Which of the following interventions is most likely to improve long-term survival in this patient?

A 72-year-old woman is brought to the emergency department due to severe dizziness, confusion, and near-syncope. Her heart rate is 32/min, and blood pressure is 75/40 mm Hg. The 12-lead electrocardiogram reveals third-degree atrioventricular block. Arrange the following interventions in the optimal chronological sequence for managing this patient's symptomatic bradycardia, from initial emergency stabilization to definitive treatment.

A 72-year-old man is brought to the emergency department by emergency medical services due to severe, rapidly progressive shortness of breath that awoke him from sleep 2 hours ago. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of 30%, chronic obstructive pulmonary disease (COPD), and chronic kidney disease. His home medications include lisinopril, metoprolol succinate, tiotropium, and as-needed albuterol. On arrival, he is in marked respiratory distress, speaking in short phrases and using accessory muscles of respiration. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $178/96\text{ mmHg}$, heart rate $112/\text{min}$, respiratory rate $30/\text{min}$, and oxygen saturation 85% on room air. Physical examination reveals an elevated jugular venous pressure at 12 cm $H_2O$. Lung auscultation demonstrates diffuse expiratory wheezing and bilateral crackles extending to the mid-lung fields. Cardiac auscultation reveals a normal $S_1$ and $S_2$ with a prominent $S_3$ gallop. Bilateral 2+ pitting lower extremity edema is present.

Laboratory results:
Leukocyte count: $9,500/\text{mm}^3$
Thyroid-stimulating hormone (TSH): $1.1\ \mu\text{U/mL}$ (normal: $0.4-4.0\ \mu\text{U/mL}$)
Free thyroxine ($T_4$): $0.5\ \text{ng/dL}$ (normal: $0.9-1.7\ \text{ng/dL}$)

Arterial blood gas (room air):
pH: $7.22$
$PaCO_2$: $35\text{ mmHg}$
$PaO_2$: $55\text{ mmHg}$
$HCO_3^-$: $14\text{ mEq/L}$

Chest radiography reveals an enlarged cardiac silhouette, bilateral perihilar alveolar opacities, and prominent interlobular septal lines. Which of the following is the most appropriate initial step in the management of this patient?

A primary care physician is evaluating a 68-year-old man who presents to an urgent care clinic with progressively worsening shortness of breath over the past 48 hours. The patient states he has been waking up in the middle of the night feeling as though he is suffocating and has required sleeping in a recliner chair. His past medical history is notable for essential hypertension, ischemic heart disease, and a 40-pack-year history of cigarette smoking. Current medications include daily aspirin, lisinopril, and atorvastatin. Vital signs show a temperature of 37.1 C (98.8 F), blood pressure of 158/92 mm Hg, heart rate of 108/min, and respiratory rate of 24/min. Oxygen saturation is 91% on ambient air. Physical examination reveals distended jugular veins when sitting upright. Cardiac auscultation demonstrates a regular tachycardia with a distinct third heart sound (S3). Lung auscultation yields bilateral crackles at the posterior lung bases without any audible wheezing. Palpation of the lower extremities reveals bilateral pitting edema extending to the knees. Which of the following is the most appropriate next step in the management of this patient?

During the physical examination of patients with suspected cardiovascular disease, assessing the arterial pulse can provide critical clues to the underlying hemodynamics and pathology. Match each of the following characteristic arterial pulse examination findings with the specific cardiovascular condition it most strongly indicates.

A $71$-year-old man is evaluated in the emergency department for severe, progressive shortness of breath over the past two days. He has a complex medical history that includes ischemic cardiomyopathy and chronic obstructive pulmonary disease. On physical examination, he is tachypneic and sitting upright in bed. Auscultation of the lungs reveals diffuse bilateral expiratory wheezing with faint crackles at the bases. To help distinguish between a pulmonary and a cardiovascular etiology for his acute presentation, the physician orders a rapid serum laboratory test that measures a specific endogenous polypeptide. The test results show a markedly elevated concentration of this polypeptide, supporting acute decompensated heart failure as the primary cause of his symptoms.

What is the primary physiologic stimulus for the secretion of the polypeptide measured in this patient?

A 62-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. His blood pressure is 195/115 mm Hg in the right arm and 170/100 mm Hg in the left arm. Heart rate is 110/min. Physical examination reveals a new diastolic decrescendo murmur at the right upper sternal border. Arrange the following steps in the most appropriate chronological order for the initial evaluation and management of this patient.

A 74-year-old woman is brought to the emergency department due to the sudden onset of severe, unremitting pain in her right leg that began 3 hours ago. She states the pain started abruptly while she was sitting in a chair. Her medical history includes hypertension, hyperlipidemia, and atrial fibrillation. Her medications include lisinopril and metoprolol; however, she admits that she has not taken her apixaban for the past two weeks due to financial constraints. Her vital signs include a blood pressure of 142/88 mmHg, a pulse of 115/min and irregularly irregular, and a respiratory rate of 18/min. On physical examination, the right lower extremity is pale and cold to the touch from the mid-calf distally. The right dorsalis pedis and posterior tibial pulses are absent to palpation and cannot be detected by hand-held Doppler. Sensation is decreased over the dorsum of the right foot, and she has mild weakness during dorsiflexion of the toes. Which of the following is the most appropriate initial step in the management of this patient?

A 68-year-old woman is brought to the emergency department by emergency medical services for severe, worsening shortness of breath over the last 24 hours. She has a history of ischemic cardiomyopathy with an ejection fraction of $30\%$, chronic obstructive pulmonary disease (COPD), and chronic kidney disease. Upon arrival, she is lethargic and confused. Her son is at the bedside and demands that she receive "only breathing treatments and no life support," despite the patient having a recently updated, legally valid advance directive explicitly requesting full interventions, including intubation and cardiopulmonary resuscitation, for acute reversible conditions.

Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $76/48$ mmHg, heart rate is $128$/min and irregular, and respiratory rate is $32$/min. Oxygen saturation is $82\%$ on room air.

Physical examination reveals jugular venous distention up to the angle of the mandible. Lung auscultation demonstrates diffuse bilateral expiratory wheezing with a significantly prolonged expiratory phase; no crackles are present. Heart sounds are rapid and irregular. The extremities are cold, clammy, and display mottled skin up to the knees.

An electrocardiogram shows atrial fibrillation with a rapid ventricular response.

Arterial blood gas analysis on room air reveals:
pH: $7.15$
$PaO_2$: $52$ mmHg
$PaCO_2$: $68$ mmHg
$HCO_3^-$: $23$ mEq/L
Lactate: $5.4$ mmol/L

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

A 62-year-old man is brought to the emergency department due to sudden-onset, severe chest pain that he describes as "tearing" and radiating to his upper back. He has a 20-year history of poorly controlled hypertension. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $215/115\text{ mm Hg}$ in the right arm and $178/92\text{ mm Hg}$ in the left arm, pulse is $112/\text{min}$, and respirations are $22/\text{min}$. Oxygen saturation is $97\%$ on room air. Physical examination reveals a bounding pulse and an early diastolic decrescendo murmur at the right upper sternal border. Electrocardiogram demonstrates sinus tachycardia and voltage criteria for left ventricular hypertrophy, but no acute ST-segment changes. A portable chest radiograph reveals a widened mediastinum. Arrange the following management steps in the most appropriate chronological order.

A 76-year-old man is evaluated in the emergency department for a sudden onset of severe lightheadedness and confusion that began one hour ago. His wife reports that he briefly lost consciousness before arrival. He has a history of hypertension and osteoarthritis. Current medications include lisinopril and acetaminophen. His temperature is 36.8°C (98.2°F), blood pressure is 82/50 mm Hg, and pulse is 32/min. Physical examination reveals delayed capillary refill and cool extremities. A 12-lead electrocardiogram demonstrates marked sinus bradycardia with no ischemic changes. He remains hypotensive despite an initial rapid infusion of intravenous fluids. Arrange the following management steps in the correct chronological sequence, from the most appropriate immediate intervention to the definitive long-term treatment assuming the underlying etiology is irreversible.

A $54$-year-old woman with a history of metastatic lung cancer is brought to the emergency department with severe shortness of breath, lightheadedness, and confusion. Her blood pressure is $80/52$ mmHg, heart rate is $124$/min, and respiratory rate is $26$/min. Pulse oximetry is $94\%$ on ambient air. Physical examination demonstrates visibly distended jugular veins, clear lung fields bilaterally, and distant, muffled heart sounds. Her systolic blood pressure drops by $18$ mmHg during inspiration. Arrange the following management steps in the most appropriate chronological sequence for this patient's acute cardiovascular emergency.