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A 68-year-old man is evaluated in the office for pain in his right great toe. Two days ago, he had coronary angiography from the right femoral artery that showed three widely patent bypass grafts and a total occlusion of the second diagonal artery. Percutaneous revascularization was attempted but was unsuccessful. The patient has a history of type 2 diabetes mellitus, hypertension, and exertional chest pain.

On examination, his toe is painful to touch but not warm (see figure). Laboratory studies show a normal hematocrit and leukocyte count; serum creatinine is 2.2 mg/dL (pre-procedure serum creatinine was 1.6 mg/dL). Urinalysis shows eosinophils. Electrocardiogram is unchanged from a previous tracing.



Which of the following is the most likely diagnosis?

A 73-year-old woman is evaluated in the office during a routine examination. She has no complaints and feels well. Her medications are levothyroxine for hypothyroidism and hydrochlorothiazide for hypertension. An electrocardiogram performed 2 years ago was normal.

On physical examination, heart rate is 42/min and regular. The remainder of the examination is normal. Her thyroid-stimulating hormone level is normal. An electrocardiogram obtained as part of the current evaluation is shown (see figure).



Which of the following diagnoses is confirmed by the electrocardiogram?

A 72-year-old man is evaluated in the office for bilateral leg pain and cramping after walking briskly up an incline. The pain is in the distal thigh and calf and is worse on the right side. He has no pain when walking downhill. The patient has a 100-pack-year smoking history, type 2 diabetes mellitus, hypertension, and heart failure. His medications are captopril, furosemide, atenolol, atorvastatin, metformin, and aspirin.

On physical examination, the blood pressure is 146/68 mm Hg and heart rate 82/min and regular. The lungs are clear. Cardiac examination reveals an S4. There is a right femoral artery bruit with absent pulses and mild dependent rubor. Ankle-brachial index is 0.8.

Which of the following is the most likely cause of this patient's symptoms?

A 62-year-old man with chronic obstructive pulmonary disease is evaluated in the emergency department for fatigue, dyspnea, anorexia, and nausea. He has a history of mild left ventricular systolic dysfunction and has been treated with an angiotensin-converting enzyme inhibitor and digoxin for approximately 6 months.

Physical examination demonstrates a heart rate of 110/min with some irregularity. Blood pressure is 110/60 mm Hg. The jugular venous pressure is not elevated. There is mild wheezing during expiration. The cardiac examination demonstrates distant heart sounds with some irregularity but no murmurs.

Laboratory Studies

Hemoglobin 11.1 g/dL
Sodium 138 meq/L
Potassium 3.4 meq/L
Creatinine 1.6 mg/dL

The electrocardiogram is shown (see figure).



Which of the following is the most likely diagnosis?

A 50-year-old man is evaluated in the emergency department because of a 6-hour history of “tearing” posterior chest pain, diaphoresis, and shortness of breath. He has never had this pain before and has no history of trauma. He has a 15-year history of hypertension treated with hydrochlorothiazide and enalapril and a 2-year history of heartburn treated with omeprazole.

On physical examination, the patient appears agitated. Temperature is 37.5 °C (99.5 °F), blood pressure is 113/48 mm Hg, heart rate is 115/min, respiration rate is 22/min, and oxygen saturation is 97% with the patient receiving oxygen, 2 L/min by nasal cannula. Lung examination reveals crackles at both bases. On cardiac examination, the S1 is faint, the P2 is accentuated, and a summation gallop (combined S3 and S4) is present. A grade 3/6 diastolic murmur is heard at the left upper sternal border; there are no rubs.

A chest radiograph shows only an enlarged heart. The electrocardiogram is shown (see figure).



Which of the following is the most likely diagnosis?

A 49-year-old man is evaluated in the emergency department for severe left precordial chest pain. The pain is sharp in quality and worsens with coughing or deep breathing. The chest pain has waxed and waned for the last 3 days and was preceded by a 3-day history of nonproductive cough, chills, myalgias, and fatigue. The patient has a history of cocaine use and a 60-pack-year smoking history. He has a 10-year history of hypertension and type 2 diabetes mellitus. His medications are lisinopril, low-dose aspirin, and glyburide.

On physical examination, temperature is 37.2 °C (99 °F), heart rate is 103/min, respiration rate is 22/min, and blood pressure is 153/92 mm Hg. The jugular veins are not distended. The lungs are clear. Heart sounds are distant with no evidence of murmur. A two-component rub is auscultated along the left lower sternal border. The remainder of the examination is normal. His electrocardiogram is shown (see figure).



Which of the following is the most likely diagnosis?

A 53-year-old man with long-standing ischemic cardiomyopathy is admitted to the intensive care unit with hypotension following a 24-hour episode of viral gastroenteritis. He is given intravenous fluids. The following day he develops chest pain, shortness of breath, and mental status changes.

On physical examination, temperature is 38.2 °C (100.8 °F), heart rate is 100/min, blood pressure is 75/45 mm Hg, respiration rate is 12/min, and he is mildly lethargic. Jugular venous pressure is difficult to assess. The lungs are clear. Cardiac examination reveals regular rhythm, a normal S1 and S2, and the presence of an S3. There is peripheral edema bilaterally to the thighs, and the extremities are cool. A pulmonary artery catheter is placed and provides the following data.

Laboratory Studies

Central venous pressure 12 mm Hg (normal, 0-5 mm Hg)
Pulmonary artery pressure 40/15 mm Hg (normal, 20-25/5-10 mm Hg)
Pulmonary capillary wedge pressure 18 mm Hg (normal, 6-12 mm Hg)
Cardiac output 3.5 L/min (normal, 4-8 L/min)

Which of the following is the most likely diagnosis?

A 32-year-old woman is brought to the hospital with chest pain after a party. She has had similar pain previously, primarily in the morning and rarely with exertion. The pain usually subsides spontaneously and occasionally is associated with diaphoresis but rarely with dyspnea. She almost lost consciousness at work during the most recent episode. The patient has occasionally inhaled cocaine. She is otherwise healthy and takes no medications. She has no family history of coronary artery disease.

On physical examination, blood pressure is 128/70 mm Hg and heart rate is 72/min. There is no jugular venous distention or carotid bruits. The lungs are clear, and cardiac examination shows a normal S1 and S2 and a faint mid-systolic click but no murmur. Electrocardiogram taken during the chest pain shows a 1-mV inferior ST elevation; a subsequent electrocardiogram taken after resolution of the pain is normal. Serum troponin concentration is elevated. Therapy with heparin, aspirin, metoprolol, and nitroglycerin is begun.

The next morning, coronary angiography shows a normal angiographic appearance of the arteries and normal left ventricular wall motion.

Which of the following is the most likely diagnosis?

A 60-year-old man is evaluated in the emergency department for chest discomfort that has been present on and off for 6 hours. The patient is treated with aspirin, an intravenous ß-blocker, and intravenous nitroglycerin. The initial electrocardiogram is shown (see figure). Initial troponin and creatine kinase–MB levels are elevated.



On physical examination, the heart rate is 60/min and blood pressure is 78/60 mm Hg. The jugular venous pressure is elevated to the angle of the jaw. The lungs are clear. On cardiac examination, the apical impulse is normal, and a parasternal lift is present. Normal S1 and S2 are heard. An S3 and a brief systolic murmur that does not change with respiration are heard along the left sternal border.

Which of the following is the most likely cause for this patient's findings?

A 66-year-old woman is evaluated in the emergency department for severe substernal chest discomfort lasting 45 minutes. She has a 10-year history of type 2 diabetes mellitus and hypertension for which she takes metformin, aspirin, and enalapril. Physical examination shows a blood pressure of 120/60 mm Hg, heart rate of 86/min, and respiration rate of 18/min. Her lungs are clear, there is no jugular venous distention, and heart sounds are normal. There is no peripheral edema. Her electrocardiogram is shown (see figure).



Which of the following is the most likely cause of chest pain in this patient?