Work with your team to answer these questions. These questions are open book.
You are working in the emergency department when you are asked to evaluate a 57 year-old man with a history of a bicuspid aortic valve and poorly controlled hypertension presenting with acute chest pain. He appears pale and diaphoretic, with a heart rate of 110 bpm and blood pressure 132/58. Exam is notable for a II/VI systolic ejection murmur and a diastolic decrescendo murmur best appreciated at the RUSB and LLSB, bibasilar crackles, and elevated jugular venous pressure. CBC is notable for WBC 14 and BMP is notable for Cr 1.8 (other labs still pending). EKG shows sinus tachycardia and 1mm inferior ST depression. Chest X-ray shows a widened mediastinum and enlarged cardiac silhouette with pulmonary vascular congestion.
What is the best next diagnostic evaluation to perform?
You are a resident covering the intensive care unit overnight and you are admitting a 66 year-old woman presenting with acute onset dyspnea and hypoxia. Her vitals include Tmax 101.8, HR 120 bpm, BP 108/64, satting 76% on RA up to 97% on 100% NRB. Exam is notable for diffuse rales (crackles) throughout both lung fields, II/VI holosystolic murmur at apex, and diminished distal pulses with slightly cool extremities. EKG shows sinus tachycardia with diffuse submillimeter ST depression.
Which of the following most likely describes the patient’s hemodynamics?
What is the most likely diagnosis?