A 68-year-old woman comes to the office due to a month-long history of worsening fatigue, shortness of breath, and dry cough.  The patient has symptoms that worsen with exertion and when lying flat.  She has had no chest pain, palpitations, or lightheadedness.  The patient has a history of hypertension and breast cancer that is in remission after surgery and doxorubicin-based chemotherapy 15 years ago.  She does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 110/62 mm Hg and pulse is 94/min.  Physical examination shows crackles at the lung bases and bilateral pedal edema.  Which of the following sets of findings are most likely present in this patient?

A 19-year-old man comes to the office due to difficulty seeing and blurred vision, which have worsened slowly over the past year.  He is a second-year college student pursuing a degree in biochemistry.  His grades are excellent, but he is concerned about the effect his poor vision has had on his classes this semester.  The patient is also an avid swimmer.  He weighs 71 kg (156.5 lb) and is 195 cm (6 ft 5 in) tall.  Physical examination shows the findings seen in the exhibits.  This patient is most likely to die from which of the following conditions?

A 67-year-old man comes to the emergency department due to progressive shortness of breath and chest tightness.  He has had no lightheadedness or syncope.  The patient takes lisinopril for hypertension and metformin for type 2 diabetes mellitus.  He has smoked a pack of cigarettes daily for the last 40 years.  The blood pressure cuff is inflated to 140 mm Hg and the pressure is released very slowly.  At 120 mm Hg, intermittent Korotkoff sounds are heard only during expiration.  At 100 mm Hg, Korotkoff sounds are heard throughout the respiratory cycle.

Item 1 of 2

This physical examination finding can be seen in which of the following conditions?

Item 2 of 2

The patient is tachypneic and unable to speak in full sentences.  Examination reveals prolonged expiration and prominent bilateral wheezing.  Heart sounds are normal.  Chest imaging shows a normal-sized heart and hyperinflated lungs with a flattened diaphragm.  Bedside echocardiogram reveals no intrapericardial fluid accumulation or pericardial thickening.  Which of the following physiologic changes is most likely to provide immediate relief in this patient?

A 34-year-old man comes to the emergency department with fatigue and lightheadedness.  The patient had an upper respiratory infection last week, and since then his energy level has been low with shortness of breath on mild exertion.  Otherwise, his medical history is insignificant.  He is a lifetime nonsmoker.  The patient’s temperature is 37 C (98.6 F), blood pressure is 80/60 mm Hg, and pulse is 120/min and regular.  His pulse becomes undetectable to palpation during inspiration.  The lungs are clear to auscultation, but the jugular veins are distended.  Which of the following is the most likely diagnosis?

A 78-year-old man is admitted to the hospital due to fatigue, orthopnea, and exertional dyspnea.  The patient takes no medications and has not seen a physician in many years.  He is a lifelong nonsmoker.  Blood pressure is 110/60 mm Hg and pulse is 64/min.  Examination reveals bibasilar crackles, elevated jugular venous pressure, and bilateral lower extremity pitting edema.  Left ventricular diastolic pressure-volume curve is shown in the exhibit (purple curve).  Which of the following is the most likely cause of this patient’s condition?

A 63-year-old man comes to the office due to exertional dyspnea that has been progressively worsening over the last 3 weeks.  He sleeps in a recliner with his head elevated because he gets short of breath when lying flat in bed.  Medical history includes gout, dyslipidemia, and hypertension.  Blood pressure is 154/89 mm Hg and pulse is 85/min.  Physical examination shows distended jugular veins in the semi-recumbent position.  An apical heave is present on cardiac examination.  There is pitting edema in the bilateral lower extremities.  Levels of which of the following substances will be higher in the pulmonary vein compared to the pulmonary artery in this patient?

A 54-year-old man comes to the office for evaluation of hypertension.  He was diagnosed with hypertension 2 years ago but has had inconsistent follow-up and has not seen a physician in the last 6 months.  The patient is not currently taking any medications but feels well and has good exercise tolerance.  He has a family history of hypertension and ischemic stroke.  His BMI is 26 kg/m².  Physical examination is unremarkable.  Serum creatinine level is normal.  The patient is started on valsartan and hydrochlorothiazide, and the following values were measured at baseline (before starting treatment) and after 3 weeks of therapy:

Which of the following best explains the observed findings in this patient?

A 33-year-old man comes to the emergency department due to 3 days of shortness of breath, profound fatigue, and chills.  The patient has a history of intravenous drug use.  He was enrolled in a methadone program but admits to relapsing last week.  Temperature is 40 C (104 F), blood pressure is 75/40 mm Hg, pulse is 122/min and regular, and respirations are 40/min.  He is admitted to the intensive care unit but dies despite treatment efforts.  Lung autopsy findings are shown in the image below.

Which of the following is the most likely diagnosis in this patient?

An 11-year-old boy is brought to the office for a routine checkup prior to enrollment at summer camp.  The patient and his mother report no health concerns.  Family history is significant for his father passing away suddenly from a heart condition 2 years ago.  The patient is at the 75th and 80th percentiles for height and weight, respectively.  Vital signs are normal.  Physical examination shows a well-appearing child.  The lungs are clear to auscultation.  Cardiac auscultation findings at the left lower sternal border are given below.  The auscultatory abnormality intensifies with the handgrip exercise.  Which of the following is the most likely diagnosis?

A 67-year-old man is found dead in his home.  The cause of death is not apparent; he had a long history of hypertension and he had a myocardial infarction a year ago.  An autopsy is performed.  Gross examination of the heart shows white scarring and enlargement of the left ventricle.  Histologic findings from a section of the left ventricle are shown below.

The type of collagen seen in the autopsy sample is most likely to be extensively found in which of the following normal body tissues?

A 52-year-old man comes to the office due to a 2-week history of progressive fatigue and exertional dyspnea.  The patient is a postal delivery worker and reports that he gets short of breath after walking a few blocks.  He has not had chest pain or palpitations.  The patient does not use tobacco, alcohol, or illicit drugs.  Cardiac auscultation reveals a murmur that is best heard when the patient sits up and leans forward.  He brings to the office the report from a recent cardiac catheterization (graph shown below).  This patient’s murmur would most likely be loudest at which of the following time points on the graph?

A 34-year-old man comes to the physician reporting one week of inability to extend his right wrist and several of his fingers on the same hand.  He first began having difficulty while trying to type his thesis for graduate school on his computer.  He is right-handed and does not recall any trauma.  He has a history of asthma that was diagnosed while he was in college.  Physical examination demonstrates impaired dorsiflexion of the right wrist with normal strength of the left wrist.  Laboratory studies show:

Serum antibodies against neutrophil myeloperoxidase are positive.  This patient most likely has which of the following conditions?

A 23-year-old woman comes to the office due to exertional dyspnea.  She occasionally has a dry cough but has had no chest pain, palpitations, or syncope.  The patient emigrated from Cambodia 3 years ago.  She had bilateral knee swelling as a child.  Cardiac auscultation findings over the cardiac apex are given below.  Which of the following is the most likely cause of this patient’s symptoms?

A 52-year-old man comes to the physician because of increasing fatigue over the last 2 weeks. He has also been experiencing exertional dyspnea and occasional headaches. Cardiac auscultation findings at the left sternal border are shown below. Which of the following is most consistent with this patient’s auscultatory findings?

Cellular physiologists are investigating the mechanisms of contraction cessation in cardiomyocytes in response to ischemic injury.  In an animal experiment, the left anterior descending coronary artery is ligated at time 0, and changes in ATP levels within the affected myocardial cells are recorded.  At which point on the graph does the affected portion of the myocardium stop contracting?

A 21-year-old man comes to the office due to recurrent heart palpitations that start and stop abruptly.  After initial workup, the physician suspects that there is an abnormal conduction pathway in this patient’s heart that bypasses the atrioventricular node.  Assuming the diagnosis is correct, which part of the patient’s ECG is most likely to be affected during normal sinus rhythm?

A 42-year-old man comes to the emergency department due to acute-onset shortness of breath. He has no medical conditions and does not use alcohol, tobacco, or illicit drugs. The patient works as a box handler at a warehouse and has excellent exercise tolerance. Family history is insignificant. Blood pressure is 98/60 mm Hg and pulse is 112/min and regular. A short systolic murmur is heard at the apex. Bilateral crackles are present on lung auscultation. Bedside echocardiography reveals a flail posterior mitral leaflet due to chordal rupture and severe mitral regurgitation. Which of the following best reflects this patient’s left ventricular hemodynamics compared to the normal heart?