A 35-year-old male with no significant past medical history presents to the Emergency Department with one day of worsening chest pain. The chest pain was abrupt in onset, is described as “sharp” in nature, and worsens with inspiration. It is primarily centered in the center of his chest but occasionally radiates to the left upper back. He feels that the pain worsens when he lays down. Vital signs are unremarkable including equal bilateral upper extremity blood pressures and radial pulses. On physical examination, he is febrile to 38.2°C. A triphasic “scratching” sound in time with the cardiac cycle is auscultated at the left lower sternal border. Initial laboratory studies show a negative troponin T and mild elevations in white blood cell count and the C-reactive protein. His ECG is shown below: ECG6.jpg Which of the following is the most appropriate next step?

A 78-year old female with severe aortic stenosis presents to the ICU following a transcatheter aortic valve replacement (TAVR). Preprocedural transthoracic echocardiography demonstrated severe aortic stenosis with left ventricular hypertrophy and an asymmetric septal bulge. Left ventricular wall thickness in the parasternal short axis view is 1.6 cm with a small cavity. Postoperatively, the patient develops sudden onset hypotension requiring vasopressor support; however, blood pressure continues to decrease despite escalating doses of norepinephrine. The vital signs are heart rate 94 bpm, blood pressure 85/54 mm Hg, respiratory rate 18/min. Transthoracic echocardiography demonstrates an underfilled left ventricle with midventricular obstruction.  What is the most appropriate next step in management?

The AG-ACNP is caring for a 79-year-old male who has been successfully resuscitated. He had a sudden, witnessed collapse in a shopping mall where he was found to be in pulseless VT. He has a prior history of CAD with a single coronary stent placed 2 years ago. He now has stable vital signs but remains comatose. His 12-lead ECG shows ST segment depressions in the anterior leads. Which statement regarding the role of cardiac catheterization in his care is true?  Cardiac catheterization is:

A 57-year-old male with a history of smoking presents to the ED with complaints of sudden, severe chest pain radiating down his back and associated dizziness. His blood pressure is 208/116. An ECG demonstrates LV hypertrophy without ischemic changes.  Which initial intervention is appropriate?

The PT has completed the evaluation for Mr. Jones and has asked you to see him for the next PT session. Mr. Jones has pain radiating into his lower leg. The POC calls for modalities, low back exercise program, and gait training for activity tolerance. Mr. Jones ask why you are not treating his lower leg. What is the best explanation?

A 56-year-old male presents to the ED with substernal chest pain, pain with inspiration, systolic apical murmur, and fever. His ECG demonstrates ST segment elevation in all leads.  This should be recognized as:

A 76-year-old female undergoes uncomplicated coronary angiography via the right femoral artery for evaluation of a newly diagnosed cardiomyopathy. She is found to be without obstructive coronary artery disease. The patient is admitted to the intensive care unit for further monitoring. Her femoral angiogram is shown in the figure that follows. Angio2.jpg Two days following admission, the patient begins to cough. Shortly thereafter, she is observed to have sudden and rapid expansion of her right lower quadrant, with associated hypotension. Which of the following is the most appropriate next step?

A 22-year-old male is admitted to the intensive care unit after sustaining a cardiac arrest while playing soccer in a rural area. Cardiopulmonary resuscitation was performed, but no automatic external defibrillator was available; he was intubated in the field because of poor mental status. He is transferred to your tertiary care ICU. Examination reveals an ejection systolic murmur, and he followed commands when sedation was lightened. Transthoracic echocardiography reveals discrete upper septal hypertrophy measuring 18 mm and an elevated left ventricular outflow velocity. He successfully passes a spontaneous awakening trial and spontaneous breathing trial. Unfortunately, at that time, he develops atrial fibrillation, became hypotensive to blood pressures of 94/52, and FiO2 was increased from 0.4 to 0.6 in response to desaturations to the low 80s. The best treatment for this patient’s atrial fibrillation is:

A patient is transferred to the ICU with a blood pressure of 90/60 mmHg, oxygen saturation of 85%, oliguria, and diffuse crackles. Pulmonary artery catheter readings reveal a cardiac output of 1.9 L/min. and a wedge pressure of 24 mmHg.  Which IV medication is appropriate to prescribe?

A 60-year-old male with a history of nonischemic dilated cardiomyopathy is admitted to the intensive care unit after presenting to the emergency department with several days of progressive dyspnea and lower-extremity swelling. He is found to be hypotensive and tachycardic and on examination is noted to be confused with edematous, cool extremities. A 12-lead ECG shows rapid atrial fibrillation with nonspecific ST-segment changes. His last transthoracic echocardiogram performed 1 year ago showed a severely dilated LV cavity with a left ventricular ejection fraction of 28%, severe mitral regurgitation, moderate aortic insufficiency, and severe tricuspid regurgitation.  In this patient, which of the following represents a contraindication to the use of an intra-aortic balloon pump (IABP)?