A 24-year-old woman comes to the office due to pressure-like, substernal chest pain that occurs when she exercises.  The patient began noticing the pain approximately 6 months ago when she started to exercise to lose weight.  Prior to that, her lifestyle was largely sedentary.  She has no associated nausea, vomiting, diaphoresis, dyspnea, palpitations, or syncope.  The patient has no significant past medical history but was told as a child that she has a "murmur."  She has no significant family history of heart disease.  Blood pressure is 130/70 mm Hg on the right and 105/55 mm Hg on the left, and pulse is 72/min and regular.  BMI is 29 kg/m2.  A palpable thrill is present in the suprasternal notch.  There is a loud midsystolic murmur best heard at the first right intercostal space.  The lungs are clear to auscultation.  What is the most likely cause of this patient's chest pain?

A 20-year-old man comes to the physician for evaluation of a murmur that was discovered on a routine physical examination. The patient has no discomfort and has not had chest pain, palpitations, dyspnea, exercise intolerance, or syncope. He has no history of chronic illness. He is a college basketball player and exercises regularly. He takes no medications. He says he sometimes smokes marijuana and drinks alcoholic beverages socially on the weekends. His uncle died while playing soccer at age 26 years. Pulse is 65/min, respirations are 12/min, and blood pressure is 117/77 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Physical examination shows clear breath sounds, no jugular venous distention, and no lower extremity edema. Cardiac auscultation discloses a faint systolic murmur heard along the lower left sternal border with the patient in the supine position. Upon standing, a grade 3/6 systolic, crescendo-decrescendo murmur is heard in the same location. Which of the following is most likely contributing to the presence of this patient's cardiac murmur?A. Abnormal opening between the left and right ventriclesB. Calcification of the aortic valveC. Dilation of the tricuspid valve annulusD. Prolapse of the mitral valve leafletE. Systolic anterior motion of the mitral valve

A 71-year-old female presents to the ED with a 2-day history of severe abdominal pain. Pain developed suddenly with no clear correlation to meals. Her symptoms were mild at first, becoming severe in the next 6 to 10 hours. She has nausea, but no vomiting or dysphagia. Her past medical history is significant for GERD, HFpEF, type 2 DM, and atrial fibrillation. She is afebrile. HR 70, BP 135/85 mm Hg. Cardiac examination reveals a 3/6 systolic murmur in L axilla and irregularly irregular heart rate. Her abdominal examination reveals mild tenderness in the mid-abdomen. Her stool is dark. Laboratory studies show Hgb 10.0 g/dL, WBC 17.5 103/mm3, Na 144 mEq/L, Cl 105 mEq/L, K 4.0 mEq/L, HCO3 20 mEq/L, Cr 1.1 mg/dL, A1c 12.6%, and INR 1.4. Medications are metoprolol, apixaban, insulin, and enalapril, but she has difficulty with medication adherence. What is the appropriate next step in evaluation?Ask StudybuddyGroup of answer choicesAndexanet alfaCT angiographyEGDColonoscopyGastric emptying study

A 57-year-old woman is brought into the emergency department because of the sudden onset of severe left-sided chest pain and shortness of breath. She had flown back to the United States yesterday following a tour of Southeast Asia. Other than feeling tired after her long trip, she was in her usual state of good health, but this afternoon she had the sudden onset of stabbing left chest pain and noted severe shortness of breath. She denies any previous history of peripheral vascular, cardiac, or respiratory disease. Past medical history is unremarkable, and she is not currently taking any medications. On examination, the patient is in severe discomfort. Temperature is 100.5°F (38°C) orally, pulse 130, respirations 26, and BP 130/90. Pulse oximetry reveals an O2 saturation of 88% while the patient is breathing room air. Physical examination is otherwise unremarkable. Stat labs show normal kidney function. A chest radiograph and ECG are obtained.  What is the most appropriate action at this time?

A 33-year-old woman presents with progressive shortness of breath. The symptoms started with exertion, but now she has dyspnea at rest. She has no previous medical problems, no family history of heart or lung disease, and she has never smoked. On examination, she has a holosystolic murmur and an S4, both heard along the left sternal border, and there is jugular venous distention. Her lungs are clear bilaterally with no wheezes or rales. Her lower extremities are nontender and symmetric in size. She is admitted and given supplemental oxygen. A chest x-ray shows mild dilatation of the pulmonary arteries, and the lung parenchyma is normal in appearance. What is the most likely diagnosis?

A 38-year-old immigrant woman comes to the Emergency Department with right-sided weakness and slurring of her speech. Initial imaging and studies are obtained, and she is found to have suffered an ischemic stroke and is treated appropriately. When you go to examine her, she has an irregularly irregular pulse, and on cardiac examination she has an early diastolic high-pitched opening snap at the apex followed by a low-pitched diastolic rumbling murmur. Upon further discussion with the family, they indicate that she does not have any chronic medical problems and has not been to the doctor since she was a baby. She had frequent throat infections as a child, but these always resolved without treatment. She takes no medications and does not smoke or drink alcohol. The mechanism by which this condition developed is most similar to which of the following other conditions?Ask StudybuddyGroup of answer choicesGraves diseaseCystic fibrosisGuillain–Barré syndromeSarcoidosisInfective endocarditis