214.An 84-year-old woman with a history of metastatic breast cancer pre-
sents to the ED with new-onset dyspnea and exercise intolerance for the
past week. She denies fever, chest pain, or cough. On examination, her
temperature is 100.3°F, BP is 70/50 mm Hg, HR is 110 beats per minute,
RR is 20 breaths per minute, and oxygen saturation is 93% on room air. As
your colleague is performing a physical examination, you place the
portable ultrasound on the heart and see a thin echo-free area around the
heart with right atrium and right ventricular collapse. Which of the follow-
ing is the most likely diagnosis?
a. Pulmonary embolism
b. Congestive heart failure
c. Massive myocardial infarction (MI)
d. Cardiac tamponade
e. Dehydration
215.A 50-year-old man with a history of hypertension presents to the ED
with severe left-sided chest pain for 1 hour. The pain radiates down his left
arm and he feels nauseated. His temperature is 98.3°F, BP is 160/92 mm Hg,
HR is 92 beats per minute, RR is 16 breaths per minute, and oxygen satu-
ration is 98% on room air. The physical examination is normal. His ECG
shows ST-segment elevations in leads II, III, and aVF. You administer
aspirin, nitroglycerin, and morphine sulfate and wait for his laboratory
results. The nurse calls you over 10 minutes later and tells you that the
patient’s BP dropped to 60/30 mm Hg with a HR of 100 beats per minute.
Which of the following most likely explains his hypotension?
a. Medication-related adverse reaction
b. Cardiogenic shock
c. Papillary muscle rupture
d. Free wall rupture
e. Rupture of the interventricular septum
Shock and Resuscitation 219