35.While discussing a case presentation with a medical student, a nearby
patient who just returned from getting an ankle radiograph done yells out in
pain. You walk over to him and ask what is wrong. He states that since
returning from the radiology suite, his automatic implantable cardioverter—
defibrillator (AICD) is discharging. You hook him up to the monitor and
note that his rhythm is sinus. You observe a third shock while the patient
is in sinus rhythm. Which of the following is the most appropriate next
step in management?
a. Send the patient back to the radiology suite for another radiograph to desensi-
tize his AICD.
b. Administer pain medication and wait until the device representative arrives at
the hospital to power off the AICD.
c. Admit the patient to the telemetry unit to monitor his rhythm and find the
cause of his AICD discharge.
d. Place a magnet over the AICD generator to inactivate it and thereby prevent fur-
ther shocks.
e. Make a small incision over his chest wall and remove the AICD generator and
leads.
36.A 55-year-old man presents to the ED with chest pain and shortness of
breath. His BP is 170/80 mm Hg, HR is 89 beats per minute, and oxygen
saturation is 90% on room air. Physical examination reveals crackles mid-
way up both lung fields and a new holosystolic murmur that is loudest at
the apex and radiates to the left axilla. ECG reveals ST elevations in the
inferior leads. Chest radiograph shows pulmonary edema with a normal-
sized cardiac silhouette. Which of the following is the most likely cause of
the cardiac murmur?
a. Critical aortic stenosis
b. Papillary muscle rupture
c. Pericardial effusion
d. CHF
e. Aortic dissection
Chest Pain and Cardiac Dysrhythmias 19